Medical advances: New research promises novel therapies for atopic dermatitis, psoriasis, acne
"We know that atopic dermatitis is incredibly common, with 10 percent to 15 percent of children in the first few years of life having atopic dermatitis. There has been a tremendous explosion of information in recent months on some of the fundamental causes and/or associations with atopic dermatitis.
"These advances are changing our understanding of disease, and also fueling more research on therapies that can utilize this improved understanding," Dr. Eichenfield tells Dermatology Times.
Over the last few years, he says there has been excellent research identifying some fundamental problems with skin barrier function in children with atopic dermatitis.
"The genetic basis for some of these barrier defects is now being well worked out. We know that a significant percentage of atopic dermatitis patients have defects in filaggrin, which is a protein that is normally present in the epidermis," he says.
Consequently, the skin barrier appears to be both structurally and functionally compromised. For example, the skin is drier because it loses water and the barrier isn't working well, and that may influence antigen exposure through the skin. There is clearly an impact on the immune response in relationship to the structural barrier dysfunction, he says.
This new information and research is being used to understand how different therapies modulate different aspects of the disease. The information is fueling a desire to look at novel ways to treat the skin and improve some of the fundamental abnormalities, such as the use of engineered emollients, or barrier function repair products, which might help to improve the innate errors in the cutaneous barrier.
Dr. Eichenfield says that over the past few years, there has been significant testing of topical corticosteroids for safety in very young children and the approval of several products down to 3 months of age. There has also been recent research on the use of nonsteroid topical calcineurin inhibitors in long-term care regimens.
"In addition, the nonsteroid barrier creams have also been introduced into atopic dermatitis therapy, and a variety of published or presented studies have shown how some of these creams are superior to traditional emollients in their steroid-sparing ability, their speed to clearing eczema, and, in some cases, their ability to treat inflammatory eczema that otherwise might require topical corticosteroids," Dr. Eichenfield says.
Other exciting developments include research into systemic therapy for severe refractory atopic dermatitis in children, and wet-wrap therapy, which is increasingly being used for children with refractory atopic dermatitis who do not respond to initial short-term medium to high strength corticosteroids.
A recent trend is the eczema centers developed both throughout the United States and around the world. These centers are a response to data showing the tremendous impact on quality of life and the functional impact of atopic dermatitis.
"Studies have shown that intensive educational programs can improve the eczema as well as improve the quality of life. These centers are developing either new clinical care models (such as multidisciplinary models that may approach the allergic component of eczema in a subset, as well as intensive hospital care) as well as providing more extended education and research," he says.
"There is now recognition that psoriasis is not uncommon in children and adolescents. There has also been a tremendous evolution in therapy," Dr. Eichenfield says.
The first large, randomized, controlled trial with etanercept treatment for children and adolescents with plaque psoriasis, which was published in the New England Journal of Medicine in January 2008, showed utility and a good safety profile for the drug.
"The pediatric dermatology community is eagerly awaiting the FDA (Food and Drug Administration) decision on whether they are going to approve this product for a psoriasis indication in children," he says, noting that etanercept is approved for several other pediatric conditions, including juvenile idiopathic arthritis.
Several other clinical trials are under way to evaluate new topical agents for adolescents and children in psoriasis, he adds.
Acne is a very common part of adolescence. It is seen in 85 percent of all teenagers at some point.
"Over the last few months, there have been several new products that have been approved for acne, including a product that uses a novel technique to solubilize benzoyl peroxide (SoluCLENZ Rx Gel, Obagi Medical); the introduction of topical dapsone gel (Aczone gel, 5 percent, Allergan); introduction of a new clindamycin phosphate 1.2 percent and benzoyl peroxide 2.5 percent gel (Acanya Gel, Arcutis Pharmaceuticals); and the first once-daily topical acne treatment that combines the retinoid adapalene and benzoyl peroxide, adapalene 0.1 percent and benzoyl peroxide 2.5 percent, Gel / (Epiduo, Galderma).
"After a fairly quiet time in topical drug development, it is exciting to have a large set of medications that we can work into our armamentarium," Dr. Eichenfield says.
For more information: Krakowski AC et al. Management of atopic dermatitis in the pediatric population. Pediatrics. 2008 Oct;122(4):812-24.
Paller AS, et al. Three times weekly tacrolimus ointment reduces relapse in stabilized atopic dermatitis: a new paradigm for use. Pediatrics. 2008 Dec;122(6):e1210-8. Epub 2008 Nov 17.
Paller AS, et al. Etanercept treatment for children and adolescents with plaque psoriasis. Etanercept Pediatric Psoriasis Study Group. N Engl J Med. 2008 Jan 17;358(3):241-51.