Assessing the Patient

Before reaching for a prescription pad, a comprehensive patient assessment is paramount. Start with a thorough history, focusing on disease severity, prior treatments, and response. The Eczema Area and Severity Index (EASI) score, while useful, doesn't always capture the full picture of a patient's suffering. Consider quality-of-life measures like the Dermatology Life Quality Index (DLQI) to understand the true impact of atopic dermatitis.

Screen for comorbidities such as asthma, allergic rhinitis, and food allergies, as these may influence treatment decisions. Don't forget to ask about mental health. Depression and anxiety are common in patients with chronic skin conditions and can significantly affect treatment adherence. A detailed discussion of patient preferences and expectations is also vital. Some patients may prefer the convenience of an oral medication (JAK inhibitor), while others may be more comfortable with an injectable biologic.

Biologics vs. JAK Inhibitors

Biologics, such as dupilumab, target specific cytokines involved in the type 2 inflammatory pathway. They have generally shown a favorable safety profile, particularly in the long term. However, they are injectables, which may be a barrier for some patients. JAK inhibitors, on the other hand, are oral medications that broadly inhibit multiple cytokine signaling pathways. While highly effective, they carry boxed warnings for serious infections, malignancy, and thrombosis. This is a direct contrast to NICE guidelines, which often suggest starting with the least invasive option.

Consider the patient's cardiovascular risk factors before prescribing a JAK inhibitor. A patient with a history of venous thromboembolism or significant cardiovascular disease may be better suited for a biologic. Similarly, screen for herpes zoster and tuberculosis before initiating either class of medication. Live vaccines should be avoided in patients on systemic immunosuppressants.

In terms of efficacy, both biologics and JAK inhibitors have demonstrated significant improvements in EASI scores and DLQI. However, head-to-head trials are limited, making direct comparisons challenging. Some data suggest that JAK inhibitors may provide faster relief of pruritus, which can be a major driver of patient distress. Ultimately, the choice depends on individual patient characteristics and risk factors.

Sequencing and Combination Therapy

What happens when the first systemic therapy fails? The optimal sequencing strategy remains unclear. Some clinicians prefer to switch to a different class of medication (e.g., biologic to JAK inhibitor or vice versa), while others may consider combination therapy. Combining a biologic with a topical corticosteroid or calcineurin inhibitor can be effective in some patients, but the long-term safety of this approach is unknown. The 2024 American Academy of Dermatology guidelines suggest considering phototherapy as an adjunct therapy before escalating to more aggressive systemic combinations.

When switching therapies, consider the reason for failure. Was it lack of efficacy, intolerable side effects, or loss of response over time? If the patient experienced a significant adverse event with one medication, it may be prudent to avoid that class altogether. If the patient initially responded well but then lost efficacy, a different mechanism of action may be more effective.

Managing Expectations and Adherence

Open and honest communication is essential for successful treatment. Patients need to understand that systemic therapies are not a cure for atopic dermatitis, but rather a way to manage the disease. Set realistic expectations about the time it may take to see improvement and the potential for flares, even while on medication.

Adherence is a major challenge with any chronic medication. Simplify the treatment regimen as much as possible and provide clear instructions on how to administer the medication. Address any concerns about side effects and emphasize the importance of regular follow-up appointments. Consider using patient support programs to help with medication access and adherence.

Limitations of Current Evidence

While numerous clinical trials have demonstrated the efficacy and safety of biologics and JAK inhibitors in atopic dermatitis, several limitations remain. Many studies have relatively short follow-up periods, making it difficult to assess long-term safety and efficacy. Head-to-head trials comparing different systemic therapies are lacking, and the optimal sequencing strategy is unknown.

Furthermore, many clinical trials exclude patients with significant comorbidities or prior exposure to systemic immunosuppressants. This limits the generalizability of the findings to real-world clinical practice. Finally, most studies are funded by pharmaceutical companies, which may introduce bias. Clinicians should carefully evaluate the available evidence and consider the potential limitations when making treatment decisions.