There May Be a 'Changing of the Guard' In Dermatology

The 2019 American Academy of Dermatology Annual Meeting took place in Washington D.C. in early March. I had attended the American Academy of Dermatology meeting every year since 1995, but I missed the meeting in 2018 because it coincided with my son’s bar mitzvah. Therefore, this meeting was a return home after being away for a while. The meeting seemed very well attended, with large representation from industry and foreign dermatologists.

As has been the case for the last decade, the main focus in medical dermatology was on the advances in biologic therapy. However, this year, there may be an evolving “changing of the guard.” While psoriasis has dominated the scientific arena for a long time, there seems to be more new data being generated in the field of atopic dermatitis. At this time, there are multiple oral and injectable therapies in development for the treatment of this condition. There has also been increased study into the natural history of atopic dermatitis, including quality-of-life metrics and associated comorbidities.

I would like to focus on a psoriasis forum, in which I was a faculty member. The form was titled “So Many Biologics, So Little Time: How to Pick Your Poison in an Era of Biologic Overload.” This course was organized by my colleague George Han, MD, PhD, of Mount Sinai Beth Israel Hospital in New York City. The content of this symposium reflected the complexity of choosing biologic therapies for psoriasis in 2019, when we now have a large number of options. Many of the newer agents have demonstrated efficacy rates which would have seemed unimaginable years ago. In addition, this newer generation has proven to be very safe, with the absence, to date, of many potential side effects seen in earlier products. I presented data on three drugs in the pipeline, some of which reach efficacy levels higher than any observed so far. This evolving market is looking to become even more competitive in the near future.

Psoriatic arthritis is the major comorbidity seen with psoriasis. Can anyone guess how many systemic and biologic therapies are now approved for both psoriasis and psoriatic arthritis? The answer is nine. They include Methotrexate, Apremilast (Otezla), Etanercept (Enbrel), adalimumab (Humira), Infliximab (Remicade), Certolizumab pegol (Cimzia), Secukinumab (Cosentyx), Ixekizumab (Taltz), and Ustekinumab (Stelara).

This session was very well-rounded. It covered a topic that is not usually discussed. That topic was “When Not to Use Biologics for Psoriasis.” As we know from our encounters in clinical practice, there are situations in which we cannot use certain or any biologic therapy. When taking a medical history, we need to ask some of the following

  1. Is there any personal history of malignancy, including lymphoma, solid tumors, or skin cancer?
  2. Is there a personal history of ulcerative colitis or Crohn’s disease?
  3. Is there a history of tuberculosis or exposure to tuberculosis?
  4. Is there a personal or family history of demyelinating disease?
  5. Is there a history of another chronicle or recurrent infection?

Some of these medical conditions will dictate avoiding certain or all therapies. In addition, some patients do not want biologic therapies, and some cannot afford them.

Taking all of these factors together, the process of decision-making in this area has become increasingly complex. The success of this session was that the lecturers thoroughly and logically examined the different variables, in order to provide a balanced way to approach these decisions.

I enjoyed my time and education in Washington, but was happy to return to my family and my patients. I look forward to the annual meeting in Denver in 2020.

Dr. Weinberg is associate clinical professor of dermatology at the Icahn School of Medicine at Mt Sinai in New York. Disclosures: Abbvie: clinical research grants, speaker’s bureau; Amgen: clinical research grants, speaker’s bureau; Novartis: clinical research grants, speaker’s bureau; Leo: clinical research grants, speaker’s bureau; Celgene: clinical research grants, speaker’s bureau; Galderma: clinical research grants; Valeant: advisory board; Lilly: speaker’s bureau; Boehringer: clinical research grants.

Illustration by April Brust

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