Eczema: Understanding the Condition and Advanced Treatment Options

Eczema: Understanding the Condition and Advanced Treatment Options

#eczema #eczematreatment #eczemamanagement #IL4 #JAKinhibitors #dermatologist #itchyskin

Dr Mok Zhun Rui, Consultant Dermatologist at The Dermatology Practice- Camden, also shared in a feature article in ChannelNewsAsia about new treatments for eczema. Do check out the link below:

Eczema, also known as atopic dermatitis, is a chronic inflammatory skin condition characterized by dry, itchy, and scaly skin. It affects approximately 10-20% of children and 1-3% of adults worldwide, significantly impacting quality of life. This article delves into the pathophysiology of eczema, traditional treatment options, and emerging therapies, including IL-4/13 inhibitors and oral Janus kinase (JAK) inhibitors.

Pathophysiology of Eczema

Eczema results from a complex interplay between genetic, environmental, and immune system factors. Key contributors include:

1. Genetic predisposition: Mutations in filaggrin (FLG) and other genes affect skin barrier function
2. Imbalanced immune response: Overactive Th2 cells produce cytokines like IL-4 and IL-13, driving inflammation
3. Skin barrier disruption: Loss of natural moisturizing factors and impaired ceramide production
4. Environmental triggers: Allergens, irritants, and stress exacerbate symptoms

Traditional Skin-directed Treatment Options

1. Topical corticosteroids: Reduce inflammation and itching
2. Topical immunomodulators: Modulates immune response to reduce skin inflammation. Non steroidal-based
3. Emollients: Hydrate and protect the skin
4. Phototherapy: Ultraviolet (UV) light reduces inflammation in the skin through suppressive effects on overactive immune cells in the skin (T-lymphocytes). This can be delivered to the whole body or on specific sites via a targeted hand piece

Systemic immunomodulatory agents

Conventional immunosuppressive agents

This class of medication have had a long track record in the management of eczema. Prior to their initiation, a series of baseline laboratory investigations will be conducted. Usually taken orally daily, these medications may have effects on the hematological, kidney or liver. Regularr surveillance with blood tests is hence important.

IL-4/13 Inhibitors

IL-4 and IL-13 cytokines play a crucial role in eczema pathogenesis. Studies have shown that eczema is caused by an inflammatory cascade of cells and signalling proteins/ cytokines. Targeting these cytokines has shown promising results in eczema management. Medications that work on IL-4 and IL-13 cytokines are usually administered subcutaneously (in the fat layer under the skin). Some common side effects include injection site reactions, headaches, nasopharyngitis and mucosal site infections e.g. conjunctivitis.

Oral Janus Kinase (JAK) Inhibitors

Janus kinases are a family of enzymes involved in the body’s inflammatory response signal transduction (JAK/STAT signalling pathway). The name is derived from the Roman figure of duality. These enzymes have similarly two domains.
JAK inhibitors modulate the immune response by blocking the activity of JAK enzymes. Clinically, this translates to less inflammation within the skin layer. Prescribed as a daily oral formulation, there are several JAK inhibitors approved for use in patients with eczema. Side effects include increased risk of infections (upper respiratory tract, herpes simplex), cardiovascular issues, headache, gastrointestinal issues

Future Directions

Going forwards, we anticipate a new era of personalised medicine. This involves tailoring treatment to individual genetic and immunological profiles. Combination treatment with the above agents can also be administered, with ongoing evaluation of clinical data.
Lastly, the skin microbiome (a complex set of microorganisms) that contributes to good skin functioning, may be a good target for the amelioration of skin quality and hence eczema.
As research continues, optimizing treatment strategies and monitoring long-term safety will remain essential.

References

1. Leung DYM, et al. (2014). New insights into atopic dermatitis. Journal of Clinical Investigation, 124(3), 943-952
2. Beck LA, et al. (2014). Dupilumab treatment for moderate to severe atopic dermatitis. New England Journal of Medicine, 371(2), 130-139
3. Simpson EL, et al. (2016). Baricitinib in patients with moderate to severe atopic dermatitis. Journal of the American Academy of Dermatology, 75(3), 555-563