Biologic therapies for atopic dermatitis showed durable effectiveness and consistent safety outcomes in randomized controlled trials and real-world studies. Dupilumab, tralokinumab, lebrikizumab, and nemolizumab improved disease signs, reduced pruritus, and enhanced quality of life across adult and pediatric patients.
“The clinical presentation of atopic dermatitis [AD] is heterogeneous and is characterized by a relapsing and remitting course,” lead author Marjolein S. de Bruin-Weller, MD, of the National Expertise Center for Atopic Dermatitis at University Medical Center Utrecht and colleagues, explained. This variability underscores the need for therapies that maintain long-term disease control.
Dupilumab demonstrated the highest persistence, with 80% to 90% of adults remaining on therapy through 3 years and about 90% of pediatric patients continuing treatment. Tralokinumab showed one- and two-year persistence rates ranging from 78% to 96% and 67%, respectively. Nemolizumab produced rapid itch relief, with reductions observed within the first week of treatment.
Adverse events observed in practice were consistent with those reported in trials but occurred more frequently in some settings. Ocular surface disease developed in up to 40% of patients treated with dupilumab in real-world cohorts, compared with lower rates in trials. For tralokinumab and lebrikizumab, ocular events were lower in controlled trials but rose to 29% and 14% in practice-based studies. Additional reported events included psoriasiform eruptions, facial dermatitis, musculoskeletal complaints, and rare cases of cutaneous T-cell lymphoma. Rates were similar to those seen with other systemic treatments.
Biologics also affected comorbid atopic conditions. Dupilumab improved mild asthma in both adult and pediatric patients and was linked to reductions in food allergen–specific immunoglobulin E levels. Tralokinumab and lebrikizumab were not approved for asthma, though lebrikizumab reduced exacerbations in biomarker-selected patients in exploratory analyses. Biomarker studies showed reductions in type 2 inflammatory markers with IL-4 and IL-13 blockade. Barrier function improved, and skin microbiome diversity increased with decreased Staphylococcus aureus colonization.
Treatment interval adjustments were feasible. Off-label extension of dupilumab dosing to every 3 or 4 weeks maintained disease control in most patients. In one registry, 83% of patients who attempted tapering remained in remission, resulting in substantial health care cost savings. Tralokinumab and lebrikizumab also demonstrated effective maintenance when shifted to every-4-week dosing following initial induction.
This narrative review synthesized evidence from randomized controlled trials and observational studies of biologics for moderate-to-severe AD, prioritizing recent peer-reviewed research. Controlled trial data were used to supplement areas with limited real-world evidence.
The review was not systematic and lacked a formal search strategy. Real-world data were abundant for dupilumab but remain limited for tralokinumab, lebrikizumab, and nemolizumab. Adverse events may be underreported in trials, and biomarker and tapering data require further validation in larger populations.
Overall, biologic therapies provided long-term disease control with consistent safety outcomes in moderate-to-severe AD. Ongoing real-world studies and upcoming phase 3 trials of novel therapeutic targets are expected to further inform treatment approaches.
The authors reported no specific funding for this review. Dr. Marjolein S. de Bruin-Weller and co-authors disclosed multiple roles as consultants, advisory board members, speakers, investigators, or grant recipients with companies developing therapies in dermatology and immunology. Full disclosures are available in the publication.
Source: Allergy