Ideal Candidates for Ruxolitinib Treatment of Atopic Dermatitis

Linda Stein Gold, MD: We have a new option now. We have a topical JAK. How have you incorporated this into your practice? Who is a good patient, and who is not a good patient?

Matthew Zirwas, MD: Other than somebody who has too much body surface area coverage, there is no such thing as a not-good patient. The home run, slam dunk patient is somebody who has atopic dermatitis on an area that is prone to adverse effects. We really do not like to use topical steroids on the face. We try to avoid areas that have thin skin to begin with and high rates of absorption, so groin, axilla, and skin folds. People who have atopic dermatitis in sensitive skin areas are slam dunk, home runs. Those areas, in my experience, are more prone to the burning and stinging seen with older nonsteroidal topicals. It is a real benefit that it is so well tolerated for those areas. Those are your really ideal patients, somebody about whom you won’t even pause for a second and think, “I’d really rather not use a topical steroid on your face, I’d really rather not use a topical steroid on your neck or your axilla or your groin where you are more prone to get striae.” Those are the really ideal patients, but I have seen really good efficacy on the areas that are thick and difficult to treat, like palms, like other extensor areas like plaques that are thick.

Wherever you get your eczema, go put it on. The term that I use for patients is, this is the wherever, whenever drug. When you look at the 52-week data, twice daily as needed, 80% people got to clear or almost clear with long-term, as-needed use. What I tell patients is, here is this cream, it is going to come with all these warnings that sound really scary; that is in there because a different medication taken as a pill might increase those risks in some people who don’t have eczema. I would not worry about them at all as long as you do not eat the cream. You’re not going to eat the cream, right? They’re like, “Of course I’m not going to eat the cream” and they say, “Is this like a steroid?” No. Put this on wherever you’ve got eczema, whenever you’ve got eczema, and when the eczema goes away, stop putting it on. No limits. I really emphasize that there are no limits. We know the label for atopic dermatitis indicates use for up to 8 weeks, but the label for vitiligo doesn’t say up to 8 weeks. We know that it’s just as safe in atopic dermatitis as it is in vitiligo, so I tell people wherever, whenever. If you need to use it every day for the next 2 months, fine. If you need to use it for 2 weeks and then you’re clear, stop using it. When your eczema comes back, start using it again whenever, wherever. The sense of control that that gives people is a huge quality of life thing because historically, they either had nonsteroidal topicals that were slow but they weren’t afraid to put them on, or topical steroids that would work fast but they were afraid to put them on. The first time we’ve got something they feel controlled, they’re like, “I hope I don’t have to use that steroid again. If my eczema flares, I put that ruxolitinib on and the next day my itch is going to be better.” Those with sensitive skin areas are your home run patients.

Linda Stein Gold, MD: So, we didn’t talk about skin of color. We know when we use steroids, especially more potent steroids, it does take some of the pigment out. Is that something we worry about with the topical JAKs?

Matthew Zirwas, MD: I have not seen any of it with the topical JAKs so far. The skin color thing is something that’s really cool to me because all of these drugs—dupilumab, tralokinumab, the topical JAKs, the oral JAKs—have taught us something. When I used to see patients with atopic dermatitis who were people of color, they would say, “My skin tone has gotten much darker, is that going to get better?” I thought it was all post inflammatory hyperpigmentation [PIH], so I would say, if we can keep your rash gone for years, maybe it will eventually get better. Whenever I saw people actually get better on these drugs, their skin tone got dramatically better in 4 months. What we learned is it’s mostly PIH. It is mostly EHH [epidermal hyperplasia hyperpigmentation]. If you’ve got 1 point of melanin in every skin layer, and you’ve got 10 skin layers, that is 10 points of melanin. If we then get rid of your epidermal hyperplasia so now you’ve only got 5 layers that each have 1 point of melanin, now you have only 5 points of melanin. We do see their skin tone get better in 4 months. I don’t tell them it’s going to go back to normal, but I tell them it is going to be much better in 4 months. That’s a totally different thing from what I told people when dupilumab first came out.

Linda Stein Gold, MD: I think a lot of that is erythema, because the erythema itself can be so difficult to really appreciate in patients with skin of color.

Transcript edited for clarity