Biologics in Atopic Dermatitis

Primary Recommendation

• The American Academy of Dermatology recommends dupilumab as the first-line systemic therapy for adults with moderate-to-severe atopic dermatitis inadequately controlled by topical therapies, with a strong recommendation based on moderate-certainty evidence 1, 2, 3

Treatment Algorithm for Systemic Therapy Selection

First-Line Biologic Therapy

• The American Academy of Dermatology strongly endorses dupilumab for moderate-to-severe atopic dermatitis, with a dosing regimen of 600 mg subcutaneous loading dose, then 300 mg every 2 weeks 4
• Dupilumab has an expected efficacy of 63-64% achieving EASI 75 at 16 weeks when combined with topical corticosteroids 4
• Dupilumab's mechanism involves blocking the IL-4 receptor α subunit, inhibiting both IL-4 and IL-13 signaling 4

Alternative Biologic Options

• Tralokinumab is an alternative first-line biologic with a strong recommendation for adults with moderate-to-severe atopic dermatitis 2, 3, 5

Patient Selection Criteria

Candidates for Biologic Therapy

• The American Academy of Dermatology recommends initiating biologics in patients with moderate-to-severe atopic dermatitis affecting multiple body areas, with inadequate response to optimized topical prescription therapies, and significant quality of life impairment 1, 2, 4, 6

Safety Profile and Adverse Event Management

Overall Safety

• Dupilumab demonstrates an excellent safety track record with few major emergent safety concerns after more than 5 years in clinical practice 4, 6

Ocular Adverse Events

• Conjunctivitis is the most prevalent adverse event, occurring in 6-15% of patients in clinical trials and up to 26.1% in real-world data 4
• The management algorithm for ocular complications includes preservative-free ocular lubricants and topical antihistamine eyedrops for mild symptoms, continuing dupilumab while treating ocular symptoms for moderate symptoms, and referring to ophthalmology for severe symptoms 4, 6

Alternative Systemic Therapies

JAK Inhibitors

• The American Academy of Dermatology strongly recommends upadacitinib, abrocitinib, and baricitinib for moderate-to-severe atopic dermatitis 2, 3, 5
• These JAK inhibitors are approved for patients who have failed other systemic therapies or when use of those therapies is inadvisable 3

Conditional Recommendations

• Phototherapy, cyclosporine, methotrexate, azathioprine, and mycophenolate receive conditional recommendations for use in atopic dermatitis 1, 2, 5

Strong Recommendation Against

• Systemic corticosteroids are conditionally recommended against for atopic dermatitis due to substantial risk of serious adverse events and rebound flares upon discontinuation 1, 2, 5

Management of Inadequate Response

Patients Requiring Alternative Therapies

• Consider alternatives to dupilumab for patients with pre-existing severe ocular surface disease, patients requiring faster onset of action, or DROSD refractory to ophthalmologic management 4

Best Biologic for Asthma with Atopic Dermatitis

Introduction to Dupilumab

• The American Academy of Dermatology makes a strong recommendation for dupilumab as first-line systemic therapy for moderate-to-severe atopic dermatitis, with all surveyed guideline workgroup members favoring dupilumab over other options 7
• Expert consensus specifically identifies that patients with comorbid diseases and dual indications should be directed toward dupilumab, as it improves both atopic dermatitis and chronic rhinosinusitis with nasal polyposis (and by extension, asthma) 8
• The 2025 EUFOREA pocket guide recommends dupilumab for type 2 asthma, reinforcing its role in airway disease management 9

Alternative Biologics

• Omalizumab is FDA-approved for allergic asthma but not for atopic dermatitis, and would require separate therapy for atopic dermatitis management 9
• Mepolizumab, Reslizumab, Benralizumab target IL-5 pathway for eosinophilic asthma but have no efficacy for atopic dermatitis, and would leave atopic dermatitis untreated 9
• Tralokinumab is FDA-approved for atopic dermatitis with strong recommendation from the American Academy of Dermatology, but is not FDA-approved for asthma and is somewhat less effective than dupilumab for atopic dermatitis at 16 weeks 7, 10
• Tezepelumab is approved for severe asthma (type 2 and non-type 2) but not for atopic dermatitis 9

Clinical Decision Algorithm

• For patients with confirmed moderate-to-severe asthma AND moderate-to-severe atopic dermatitis, the first-line choice is to initiate dupilumab 600 mg loading dose, then 300 mg every 2 weeks 7
• Consider alternative only if pre-existing severe ocular surface disease exists, patient is female planning pregnancy, or dupilumab-related ocular disease is refractory to ophthalmologic management 7, 9
• Do not use separate biologics for each condition when dupilumab can treat both simultaneously 8