Role of Disease-Modifying Therapy in Atopic Dermatitis

Elaine Siegfried, MD: We wish we had a good definition for disease modifying treatments. In the rheumatologic literature, and for joint disease, they talk about DMARDs, disease modifying antirheumatic drugs. I made up a term for that—disease modifying anti-inflammatory medications. You know? I think that one day we’ll have a better definition about that. We don’t really have that now. We do have some data that suggest that if you get good control of atopic dermatitis when you’re very young, that not only will it help you outgrow your eczema, but also may minimize your risk for getting the other atopic diseases that tend to follow the skin disease.

And so we think that there’s an opportunity for disease modification, but we don’t have great data because we don’t know really why some people outgrow their disease and other people don’t. But I do think that for children whose disease is well controlled early, that there may be the possibility that it helps them outgrow their disease. At least that’s what we tell people.

There’s not any one treatment that’s disease modifying. I think you can get disease modification with any treatment, but that requires adherence. When you’re a very young child and you have a parent who’s very organized who also has time to devote to treating their child with that disease with simple topical treatments, that can be disease modifying. I actually have a really great study looking at children, babies born into families that are atopy prone, and doing fairly intensive topical treatment with daily bathing and the use of bland emoluments and staying away from complex topical products, that it significantly decreases the chances of their developing atopic dermatitis in the first place. So that’s got to be in the disease modifying category. And so any treatment that you do has the potential for minimizing the long-term impact of progressive atopy.

Once you already have bad disease, we don’t know whether any treatment that we use can help them outgrow their disease or get the disease to ever go away, and that’s one of the questions that is a big unknown. It’s going to take a long time to get the answer for, is once you start somebody on a systemic immunosuppressant or a targeted biologic agent, are they ever going to be able to come off of it? We don’t know the answer to that question.

Now I don’t have that experience with our newest biologic agent, dupilumab. It’s only been on the market for 2 weeks for adolescents and for a couple of years for adults, and we have children that we’ve been following for a couple of years who are on that drug. So it’s way too soon to take anybody off the drug.

I’ve had a pretty good percentage of people who I have to put on methotrexate, and sometimes I put them on methotrexate as early as the first year of life if they’re beyond topical therapy. But for a big proportion of children who have had the opportunity to remain controlled on methotrexate, I’d say about 50% of them can come off of the drug.

I think that payers are paying attention to this disease now because we have a new targeted very expensive medication. And it’s that part about the cost to society and the cost to the payers. But now that there is a treatment it’s being recognized, the impact of the disease is being recognized, and so it’s wonderful to have that kind of attention to the disease. And having an expensive drug is life altering for people and well worth it. The Institute for Clinical and Economic Review also did a very sophisticated analysis about the cost of the new medication compared to the burden to society, and it’s well worth it. So it’s nice to be able to have those options, and it’s wonderful for the patients.

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