With a wider range of treatments, pharmacists will be able to offer people with eczema even more effective therapy than they can at present, writes Steve Titmarsh…

The choice that could be available in years to come may make the goal of precision medicine, tailoring treatment to each individual, more attainable in future.

If nothing else, more new medicines (should they make it through the research and development process) will hopefully offer better outcomes for more people with this complicated and debilitating disease.

In the UK, the National Eczema Society says on its website that there are up to 70 new drugs in development for atopic eczema (also referred to as atopic dermatitis).

The Society says it is thrilled to see a wave of exciting research studies focussed on the causes and treatments of eczema. ‘After years of being overlooked, eczema is finally receiving the attention it deserves, and this positive trend is paving the way for a brighter future.

With around 70 new treatments currently in development for atopic eczema, there’s a renewed sense of hope for the eczema community. Together, we’re moving towards a world where better solutions and improved care are within reach!’ it comments.¹

Research into other inflammatory conditions such as arthritis is providing new insights in the inflammatory process that is thought to be the cause of eczema.

New treatments for atopic eczema include those belonging to a group of antibody therapies known as biological checkpoint inhibitors (also referred to as ‘biologics’).

They work by acting on interleukins, which are involved with the inflammatory process, and are mainly monoclonal antibodies such as dupilumab, tralokinumab and lebrikizumab.²

Lebrikizumab is available as a subcutaneous injection. The drug is designed to neutralize interleukin-13 (IL-13), a key cytokine involved in atopic dermatitis.

In July 2024 it was recommended by the National Institute for Health and Care Excellence (NICE) as an option for the treatment of moderate to severe atopic dermatitis in people aged 12 years and over with a bodyweight of 40kg and over.

Access to the treatment is via a commercial arrangement between the manufacturer – Almirall – and the NHS. Treatment with lebrikizumab has to be stopped after 16 weeks if the atopic dermatitis has not responded adequately. An adequate response is defined as:³

• at least a 50% reduction in the Eczema Area and Severity Index score (EASI 50) from when treatment started, and

• at least a 4‑point reduction in the Dermatology Life Quality Index (DLQI) from when treatment started.

Janus kinase (JAK) inhibitors have a broad range of effects on the immune system and are available in oral and topical formulations. Abrocitinib and upadacitinib have already be recommended for use by the NHS within certain parameters.⁴ A third JAK inhibitor – delgocitinib – is under review by NICE.⁵ 

There are a number of different treatments in development aimed at reducing itch associated with eczema, which, according to the National Eczema Society, is one of the most challenging and disruptive symptoms of the condition.²

For example, tapinarof is the first of a new class of non-steroidal, topical aryl hydrocarbon receptor agonists. Activation of aryl hydrocarbon receptors results in the modulation of multiple signalling pathways involved in skin homoeostasis and inflammatory responses.⁶ Other similar drugs under investigation include lotamilast and difamilast.

Other compounds being investigated include a phosphodiesterase type-4 inhibitor, roflumilast, which has been approved in a cream formulation for mild to moderate atopic dermatitis in the US.^2,7

Tyrosine kinase inhibitors have shown promise in the treatment of eczema.² For example, brepocitinib, which inhibits JAK as well as tyrosine kinase has been found to be effective and well tolerated by people with mild to moderate eczema.⁸

Other approaches

Eczema is a complex disease involving the interaction of many components including environment, skin microbiome and the epidermal barrier.

So the search for therapeutic targets goes beyond the immune system itself and the inflammation that results along with the itch-scratch cycle.⁹

In terms of the skin microbiome a number of strategies to restore or change its composition have been suggested and are in the early stages of investigation.⁹

The dry, sensitive highly permeable skin seen in individuals with eczema is thought to be result of a dysfunction of the epidermal barrier function, possibly caused by mutations in genes encoding for structural elements in the skin such as filaggrin, and inflammation resulting in impaired epidermal barrier function.

So, restoring barrier epidermal barrier function in individuals with eczema is another approach to treating the disease.⁹

Optimising treatment

Exciting as all the research into new treatments is, the real challenge for clinicians is to optimise treatment by identifying which approaches work best for each individual patient – sometimes referred to as precision medicine.

It is the nirvana of all medical treatment and slowly researchers and clinicians are beginning to unlock at least some of the information that is needed to achieve it.

Having a wide range and large number of treatments available can seem daunting in terms of deciding which to use but it also improves the prospects of finding the right one for each person.

Conclusion

The future looks promising for people with eczema given the large number of new treatments in development and the advances in the understanding of the underlying causes of the disease.

The hope is that with a wider range of effective treatments clinicians will be able to offer people with eczema even more effective therapy than they can currently, not only as a result of the development of new treatments but also because of a greater understanding of which of those treatments best suits a particular individual. 

References

1. National Eczema Society. National Eczema Society and Research (https://eczema.org/research/national-eczema-society-and-research; accessed September 2024).

2. National Eczema Society. Eczema treatment research pipeline (https://eczema.org/research/eczema-research-pipeline; accessed September 2024).

3. National Institute for Health and Care Excellence. Lebrikizumab for treating moderate to severe atopic dermatitis in people 12 years and over. Technology appraisal guidance (TA986) (www.nice.org.uk/guidance/ta986; accessed September 2024).

4. National Institute for Health and Care Excellence. Abrocitinib, tralokinumab or upadacitinib for treating moderate to severe atopic dermatitis. Technology appraisal guidance (TA814) (www.nice.org.uk/guidance/ta814; accessed September 2024).

5. National Institute for Health and Care Excellence. Delgocitinib for treating moderate to severe chronic hand eczema ID6408 (www.nice.org.uk/guidance/indevelopment/gid-ta11506; accessed September 2024).

6. Silverberg JI, Boguniewicz M, Quintana FJ, et al. Tapinarof validates the aryl hydrocarbon receptor as a therapeutic target: A clinical review. J Allergy Clin Immunol 2024;154(1):1–10.

7. McCormick B. FDA approves roflumilast for patients 6 years and older with atopic dermatitis (www.ajmc.com/view/fda-approves-roflumilast-for-patients-6-years-and-older-with-atopic-dermatitis; accessed September 2024)

8. Landis MN, Arya M, Smith S, et al. Efficacy and safety of topical brepocitinib for the treatment of mild-to-moderate atopic dermatitis: a phase IIb, randomized, double-blind, vehicle-controlled, dose-ranging and parallel-group study. Br J Dermatol 2022;187(6):878–87.

9. Bieber T. Atopic dermatitis: an expanding therapeutic pipeline for a complex disease. Nat Rev Drug Discov 2022;21(1):21–40.