Tralokinumab in Atopic Dermatitis: A Profile of Its Use

Biologic and Small Molecule Therapy in Atopic Dermatitis

Atopic dermatitis is a chronic inflammatory dermatosis characterized by pruritic, scaly, erythematous lesions. Its incidence varies but is estimated to be approximately 20% in children and between 7 and 14% in adults, with variation amongst countries. It is a multifactorial condition, with a complex interplay between genetic, immunological, and environmental factors. Research into the inflammatory response has identified new therapeutic targets that work to reduce inflammation and subsequently reduce flares. This study explores existing therapeutic agents for atopic dermatitis as well as newer therapies such as biologics and small molecules, drawing upon each agent's mechanism of action, relevant landmark clinical trials, efficacy, and safety profile. Current therapies include emollients, corticosteroids, cyclosporine A, calcineurin inhibitors, phototherapy, and methotrexate. Biologics described include dupilumab, tralokinumab, lebrikizumab, nemolizumab, and rocatinlimab. Small molecules inhibitors include Janus kinase inhibitors, phosphodiesterase 4 inhibitors, transient receptor potential vanilloid subfamily V member 1 antagonist, and aryl hydrocarbon receptor antagonist.

Biologic and small-molecule therapy for treating moderate to severe atopic dermatitis: Mechanistic considerations

Atopic dermatitis (AD) is a complex and heterogeneous skin disease for which achieving complete clinical clearance for most patients has proven challenging through single cytokine inhibition. Current studies integrate biomarkers and evaluate their role in AD, aiming to advance our understanding of the diverse molecular profiles implicated. Although traditionally characterized as a TH2-driven disease, extensive research has recently revealed the involvement of TH1, TH17, and TH22 immune pathways as well as the interplay of pivotal immune molecules, such as OX40, OX40 ligand (OX40L), thymic stromal lymphopoietin, and IL-33. This review explores the mechanistic effects of treatments for AD, focusing on mAbs and Janus kinase inhibitors. It describes how these treatments modulate immune pathways and examines their impact on key inflammatory and barrier biomarkers.

Updates in atopic dermatitis for the primary care physician: A review of advances in the understanding and treatment of atopic dermatitis

Atopic dermatitis (AD) is a common inflammatory skin condition occurring in both pediatric and adult patients. Pruritus is a clinical hallmark of the disease, and patients with AD often experience disruptions to their quality of life. The pathogenesis of AD is a complex and multifactorial interplay between genetic factors, epidermal barrier disruption, and immune dysregulation. Clinically, AD is characterized by pruritus, eczematous skin changes, and age-specific lesion distribution patterns. Infants and young children tend to have AD lesions on their face and extensor surfaces of their extremities while older children and adults tend to have AD lesions on flexural surfaces of their extremities. Many patients also experience a chronic and relapsing disease course. Due to the chronicity and severe pruritus, lesions often undergo secondary changes like lichenification. Patients with AD can experience a number of comorbidities including other atopic disease (i.e. allergic rhinitis, asthma), skin infections, cardiovascular, and neuropsychiatric illnesses. Management of AD depends on the severity of the disease as well as the distribution of the disease. Traditionally, treatment of AD included the use of moisturizers / emollients, topical corticosteroids or topical calcineurin inhibitors, or systemic therapy with non-selective immunosuppressants such as corticosteroids, cyclosporine, azathioprine, or similar. However, in the past decade, new biologic and small molecule drugs, both topical and systemic, have become important therapeutic options for AD patients, especially for those with moderate-to-severe disease. The development of these medications, following decades of research to better understand AD, are designed to specifically target various components of immune dysregulation and inflammation implicated in the pathogenesis of AD. Their successful development and deployment now allow for an exciting new era of treatment for individuals suffering from atopic dermatitis.

Diversity of atopic dermatitis and selection of immune targets

Atopic dermatitis (AD) is a heterogeneous immune-mediated skin disorder affecting people of all ages and ethnicities. Despite the development of targeted therapeutics such as biologics and Janus kinase inhibitors, attaining complete clinical efficacy remains difficult. This therapeutic challenge may be attributed to the complex pathogenesis of AD. Although the TH2 axis has been extensively studied, recent advancements have started to reveal the involvement of additional immune pathways including TH1, TH17, and TH22. Understanding the interplay of these immune axes may contribute to a more personalized therapeutic approach based on patients' molecular profile, with the prospect of improving clinical outcome. This review will discuss studies exploring the molecular profile of AD in both skin and blood across age, ethnicity/race, disease chronicity, IgE levels, filaggrin mutation status, and AD association with other atopic conditions. Moreover, it will explore the potential of personalized treatment strategies based on a patient's distinct immune signature.

Novel Immunopharmacological Drugs for the Treatment of Allergic Diseases

The exponential rise in the prevalence of allergic diseases since the mid-twentieth century has led to a genuine public health emergency and has also fostered major progress in research on the underlying mechanisms and potential treatments. The management of allergic diseases benefits from the biological revolution, with an array of novel immunomodulatory therapeutic and investigational tools targeting players of allergic inflammation at distinct pathophysiological steps. Prominent examples include therapeutic monoclonal antibodies against cytokines, alarmins, and their receptors, as well as small-molecule modifiers of signal transduction mainly mediated by Janus kinases and Bruton's tyrosine kinases. However, the first-line therapeutic options have yet to switch from symptomatic to disease-modifying interventions. Here we present an overview of available drugs in the context of our current understanding of allergy pathophysiology, identify potential therapeutic targets, and conclude by providing a selection of candidate immunopharmacological molecules under investigation for potential future use in allergic diseases.

Skin infections during dupilumab monotherapy in moderate-to-severe atopic dermatitis - a meta-analysis of randomized clinical trials

OBJECTIVE

Atopic dermatitis (AD) increases the risk of bacterial and viral cutaneous infections. This study assesses the risk of skin infections related to dupilumab monotherapy in moderate-to-severe AD.

METHODS

We searched PubMed/Medline, Embase, Web of Science, ClinicalTrials.gov, and Cochrane Library. For gray literature, Google Scholar was searched. A meta-analysis of randomized clinical trials (RCTs) for overall skin infections, eczema herpeticum, nonherpetic skin infections and subgroup meta-analysis based on overall herpetic infection type was performed.

RESULTS

We observed a statistically significant (p < 0.005) lower incidence rate in the dupilumab group compared to placebo for overall skin infections (Risk Ratio [RR] = 0.59, 95% confidence interval [CI]: [0.47, 0.75], P < 0.0001) and nonherpetic skin infections (RR = 0.42, 95% CI: [0.27, 0.66], P = 0.0001). For herpetic infections in 2b phase studies a meta-analysis demonstrated significantly higher events in dupilumab group compared to placebo (RR = 3.38, 95% CI: [1.98, 5.76], P < 0.00001, test for subgroup differences: P = 0.02, I2 = 65.6%).

CONCLUSIONS

In moderate-to-severe AD, dupilumab in monotherapy may be an effective and safe therapeutic approach, not associated with an increased risk of overall skin infections and nonherpetic skin infections. Due to the lack of statistical significance in heterogeneity associated with potential confounders in some cases, results should be interpreted cautiously.

REGISTRATION

The meta-analysis was registered in PROSPERO, ID: CRD42023441346.

Current and Emerging Therapies for Atopic Dermatitis in the Elderly

Atopic dermatitis (AD) in the elderly has recently emerged as a distinct subgroup of AD, garnering widespread concern due to its increasing global incidence rate. Epidermal barrier dysfunction, inflammatory response, and chronic pruritus interact with each other, contributing to the pathogenesis and pathophysiology of AD in the elderly. Although fundamental medications are essential for managing AD in the elderly, older adults often struggle with regular usage of moisturizing emollients, topical medications, and avoidance of environmental triggers, leading to recurrent or even exacerbated disease progression. Therefore, a systematic medication approach is necessary to control pruritus and skin lesions. Traditional systemic treatments may not adequately meet the treatment needs of moderate and severe AD in the elderly and may even pose certain safety risks. Biologics and Janus kinase (JAK) inhibitors, exhibiting excellent clinical efficacy, have made significant breakthroughs in AD treatment. Existing evidence suggests that dupilumab, a human monoclonal IgG4 antibody, has been confirmed as an effective and safe first-line systematic treatment for moderate to severe AD in the elderly, with no notable differences between adults and the elderly. However, the limited inclusion of elderly patients in related clinical studies hinders the generalizability of these findings. As older patients face a higher risk of adverse events with JAK inhibitors, JAK inhibitors are recommended when no other suitable treatment options are available. Obtaining population-specific data is crucial for making evidence-based treatment choices when managing AD in older adults with JAK inhibitors.

Are Antimicrobial Peptides a 21st-Century Solution for Atopic Dermatitis?

Atopic dermatitis (AD) is a chronic inflammatory skin disorder that is the result of various environmental, bacterial and genetic stimuli, which culminate in the disruption of the skin's barrier function. Characterized by highly pruritic skin lesions, xerosis and an array of comorbidities among which skin infections are the most common, this condition results in both a significant loss of quality of life and in the need for life-long treatments (e.g., corticosteroids, monoclonal antibodies and regular antibiotic intake), all of which may have harmful secondary effects. This, in conjunction with AD's rising prevalence, made the development of alternative treatment strategies the focus of both the scientific community and the pharmaceutical industry. Given their potential to both manage the skin microbiome, fight infections and even modulate the local immune response, the use of antimicrobial peptides (AMPs) from more diverse origins has become one of the most promising alternative solutions for AD management, with some being already used with some success towards this end. However, their production and use also exhibit some limitations. The current work seeks to compile the available information and provide a better understanding of the state of the art in the understanding of AMPs' true potential in addressing AD.

Review of Tralokinumab in the Treatment of Atopic Dermatitis

OBJECTIVE

To review pharmacokinetics, efficacy, and safety of tralokinumab in treatment of atopic dermatitis (AD).

DATA SOURCES

Literature review was conducted using MEDLINE (PubMed), EMBASE, and ClinicalTrials.gov for articles published between January 2010 and May 2022.

STUDY SELECTION AND DATA EXTRACTION

Articles in English discussing tralokinumab in AD were included.

DATA SYNTHESIS

In one phase 2 trial, more subjects treated with tralokinumab 150 and 300 mg achieved an Investigator's Global Assessment (IGA) of 0/1 with minimum ≥2 point IGA reduction (23%), versus placebo (11.8%, P = 0.10). During 2 phase 3 trials, more subjects treated with tralokinumab achieved IGA success (ECZTRA 1: 15.8% and ECZTRA 2: 22.2%), versus placebo (7.1% and 10.9%, respectively; P = 0.002 and P < 0.001). During one phase 3 trial, in conjunction with topical corticosteroids (TCS), more subjects treated with tralokinumab 300 mg achieved IGA success (ECZTRA 3: 38.9%), versus placebo (26.2%, P = 0.015). During another phase 3 trial in subjects with resistance or contraindication to oral cyclosporine, more subjects treated with tralokinumab 300 mg achieved an Eczema Area Severity Index 75 (64.2%), versus placebo (50.5%, P = 0.018).

RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE

Tralokinumab is efficacious for moderate-to-severe AD, as monotherapy, in conjunction with TCS, and resistance or contraindication to cyclosporine. Although IL-4 and IL-13 are both implicated in AD's pathogenesis, IL-13 is overexpressed, and head-to-head trials are needed to assess efficacy of tralokinumab, versus dupilumab. Compared with upadacitinib and abrocitinib, tralokinumab is not associated with black-box warnings.

CONCLUSIONS

Tralokinumab is an efficacious and safe systemic treatment for moderate-to-severe AD.

Current Use of Probiotics and Prebiotics in Allergy

The microbiome plays an important role in the pathogenesis of allergic diseases. This review updates the reader on studies aimed at influencing allergic diseases through modulation of the gut microflora. A nonsystematic review of the literature was performed, focusing on relevant trials evaluating the effect of probiotics/prebiotics/symbiotics in the prevention and treatment of allergic disease. For each allergic disease, we were able to find not only a substantial number of clinical trials but also systematic reviews. Specific guidelines, based on systematic reviews and meta-analyses, are available for the prevention of allergic disease and for the treatment of food allergy. In each of the areas examined-allergic rhinitis, allergic asthma, atopic dermatitis, food allergy, and gastrointestinal allergies-there are substantial uncertainties in the efficacy of gut microflora modulation in prevention and treatment. At present, practicing clinicians can avail themselves of intestinal flora modulators as an adjunct in the prevention of atopic dermatitis but not of other forms of allergic diseases. Their effects on the treatment of allergic diseases remain controversial.