Dermatologists call for personalized treatment, subjective symptom focus for eczema

The chronic nature of atopic dermatitis (AD), or eczema, driven by a complex interplay of genetic, environmental, and allergic factors, has led to calls for insurance reimbursement evaluations to consider a broader range of factors, especially as new treatments continue to emerge.

Professor Ahn Ji-young of the National Medical Center’s (NMC) Department of Dermatology emphasized the need for a more nuanced approach: “The assessment of AD severity must prioritize patients' subjective symptoms,” she said during the 2024 Pfizer Press University briefing hosted by Pfizer Korea on Tuesday in Seoul.

Characterized by type 2 inflammation, AD involves inflammatory cytokines like IL-4, IL-13, TSLP, and IL-31, which drive the disease’s progression and worsen symptoms. The relentless itching associated with AD fuels a vicious cycle, compromising the skin barrier and inviting allergens and pathogens that exacerbate the condition. 

“The primary symptom of AD—itching—both defines the disease and accelerates its progression,” said Ahn . 

Severity is currently measured by the Eczema Area and Severity Index (EASI) score, with the EASI-75 score—indicating a 75 percent improvement in lesion extent and severity—used to assess treatment effectiveness and determine insurance coverage. However, many patients argue that this metric does not fully capture the impact of their condition.

“We recognize the importance of objective tools, particularly given the potential for patients to exaggerate symptoms for insurance purposes,” Ahn said. “But it’s frustrating because this approach doesn’t address the core issue. Improvements in subjective symptoms, such as itching, are crucial and should be considered in reimbursement decisions.”

The challenge of treating itching remains significant, as it is often overlooked as a key criterion for insurance coverage.

“Personalized treatment is increasingly vital because AD varies greatly among patients, not only in inflammation but also in the diverse ways inflammatory substances affect individuals,” Ahn said. “This necessitates a tailored approach to treatment.” 

Until 2021, Regeron and Sanofi’s Dupixent (dupilumab) was the sole biological treatment available for AD, leaving patients with few options. Traditional treatments like cyclosporine and methotrexate, while common, did not specifically target the overactive type 2 immune response, instead suppressing overall immune activity. This broad approach often led to more side effects and reduced effectiveness.

“We've shifted towards targeted therapies to address this issue,” said Professor Jang Yong-hyun, Medical Insurance Director of the Korean Dermatological Association and Chair at Kyungpook National University School of Medicine. “Our new approach involves biological agents and Janus kinase (JAK) inhibitors designed to specifically target key cytokines like IL-4 and IL-13 through monoclonal antibodies.”

This targeted strategy aims to enhance efficacy and minimize toxicity by addressing the specific mechanisms of the condition. 

Although doctors use the EASI-75 score to guide treatment decisions—often opting for advanced therapies such as Dupixent, Arcalyst (rilonacept), or JAK inhibitors like Olumiant (baricitinib) or Rinvoq (upadacitinib) for patients scoring above 23 points—not every patient responds to these treatments. This makes it crucial to tailor therapies to individual needs, addressing specific symptoms like itching and skin lesions. 

“If one treatment fails, another option should be considered. It’s quite obvious,” said Jang.

European guidelines strongly recommend JAK inhibitors (abrocitinib, baricitinib, and upadacitinib) alongside biologics (dupilumab and tralokinumab) for severe AD. Similarly, American guidelines support these treatments, even though baricitinib has not yet received FDA approval.

Korean guidelines have also undergone significant changes. The 2024 update, which expands from the 2021 guidelines that approved only Dupixent, now includes new biologics such as Lilly’s Ebglyss (lebrikizumab), though it is not yet widely used. This revision, the first in nine years, now endorses the interchangeable use of three biologics and JAK inhibitors.

“The guidelines should align closely with actual patient treatment and insurance coverage,” Jang said. “They shouldn’t exist in isolation from one another.”

Both the Korean Atopic Dermatitis Association and the Korean Dermatological Association advocate for treatment decisions, especially for severe cases (EASI score of 23 or higher), to be made collaboratively between doctors and patients to identify the most effective medication—whether a JAK inhibitor or biologic.

“Since no single treatment guarantees success for everyone, having alternative therapies available is crucial if the initial one fails,” Jang said, emphasizing the importance of treatment switching to provide tailored options based on individual patient needs. “This remains the consistent stance of the associations, and we plan to continue advancing this dialogue.”

Jang referenced the phase 3 JADE COMPARE study, in which Pfizer’s Cibinqo (abrocitinib), a newer drug, was tested against dupilumab. The JADE EXTEND study then focused on patients who did not respond to dupilumab. These non-responders were first given a placebo for four weeks, followed by either 100 mg or 200 mg of abrocitinib. Approximately 80 percent of these patients achieved a 75 percent reduction in their EASI score (EASI-75).

“This data strongly supports the idea that patients who don’t respond to one treatment can still find relief with another,” said Jang. 

Currently, Korea’s Health Insurance Review & Assessment Service (HIRA) demands extensive phase 3 trial data to support new treatments. However, Ahn argues that “not everything is as clear-cut,” pointing out that evidence levels vary for different medications. 

Ahn noted that while cyclosporine, an older drug not initially approved for AD, became widely used based on clinical adaptation, newer treatments face frustratingly rigid data requirements.

Jang added, “The adequacy of data can be subjective—what seems sufficient to one might seem lacking to another. Given that these treatments are already approved, it doesn’t make sense to restrict their interchangeability.”

For instance, if a patient suffers from severe itching but has minimal skin lesions, a JAK inhibitor might be preferred over biological treatments, which generally target IL-4 and IL-13.

JAK inhibitors, capable of blocking multiple pathways including IL-31, may offer better relief from itching. If itching improves but skin doesn’t fully heal, patients might then switch to dupilumab.