Ask the Ecz-perts: Biologics

In Ask the Ecz-perts, leading medical experts answer your most pressing questions about eczema and its related conditions.

In this edition of Ask the Ecz-perts, dermatologists Peter Lio, MD, and Amy Paller, MD, answer your questions about biologics.

Lio is assistant professor of clinical dermatology and pediatrics dermatology at Northwestern University Feinberg School of Medicine and the founding director of the Chicago Integrative Eczema Center.

Paller is chair of the department of dermatology at Northwestern University Feinberg School of Medicine and a pediatric dermatologist at the Ann and Robert H. Lurie Children’s Hospital of Chicago.

What percentage of your patients respond to Dupixent? How long does the treatment typically last? What percentage get off the medicine?

About 75% of my patients get at least 75% better (easy to remember!). That still leaves a quarter who are not where they need to be. Most stay on dupilumab (Dupixent) for at least six months; some longer. But if they are doing great (clear or just about totally clear and not needing much topical therapy), we talk about taking a holiday and seeing how things go.

I’ve been on Dupixent for about a year and two months, with less frequent flares over time. I would eventually like to wean off of Dupixent. How long should I stay on it initially, such as another 10 months so that I would have a two-year baseline, for example? And, when weaning off, is it best to just stop it or gradually taper off?

It’s so good to hear that things are going well. It is a little tricky to figure out how to come off. I have usually been going to monthly dosing for a few months and then stopping. It may be even better to just stop when it is time, though it is hard to know. If your doctor is interested, they can read my paper here which has some of the direct data I was referencing.

What is the connection between eczema and asthma since we know that Dupixent is approved for both?

Eczema and asthma are both TH2 type inflammatory conditions. They often do run together and have a lot in common — so much so that Dupilumab works for both of them and has FDA approval for both conditions.

Are there any indications that Dupixent can cause severe withdrawal symptoms like topical steroid withdrawal?

Honest to goodness, we have not seen this. That, of course, does not mean it is impossible or doesn’t happen, but I’m very happy to say that most people do not seem to suffer withdraws at all. In fact, there tends to be a relative remission state afterward.

I travel to foreign countries and am required to take some shots to prepare for my visit. Does this mean I should interrupt taking my Dupixent shot on schedule?

If you are referring to required vaccinations before traveling, live vaccines should not be used while on dupilumab (Dupixent), as they have not been studied. This is something you’d want to discuss with the travel clinic or the administering physician. More information on that can be found here. 

I’ve started doing core-strengthening exercises, so taking the Dupixent shots in my stomach have become more painful. Are there other areas of the body that could be a better alternative?

I think the belly is the best area in general, but it is certainly worth it to try the thigh. Some patients prefer that. I also think that there are a few things to help mitigate the pain:
1. Use a cold pack to the skin for a bit before the shot.
2. Make sure the dupilumab is warmed up to room temperature.
3. If you can use a “buzzy,” that helps as well.

I know many more biologics are coming out as well as JAK inhibitors. Do you lean more toward one over the other, or do you think having both might even improve the course of treatment for patients? Perhaps those who don’t do well on a biologic may benefit from using both treatments?

This is an important line of questioning that everyone is starting to explore in the research community now. I think the safest answer is that we don’t yet know how things will fit together, but it does seem that some JAK inhibitors are even more powerful than even dupilumab against inflammation. An awesome comparison can be found here.

Peter Lio, MD, assistant professor of clinical dermatology and pediatrics dermatology at Northwestern University Feinberg School of Medicine and founding director of the Chicago Integrative Eczema Center

If someone is on Dupixent, should they avoid working in an office if possible due to COVID-19?

Theoretically, there is no increased risk of COVID-19 while on Dupixent. It works by suppressing a very specific arm of the immune system called TH2, which is only known to be helpful in handling parasite infection. We know of no issue in handling viral infections. As such, it may be the safest “systemic”/non-topical medicine out there during this pandemic.

Is there research into possibly converting Dupixent injections into a pill form?

That would be amazing, but the chemical structure of Dupixent is that of a monoclonal antibody. These are very large and are dissolved internally when we swallow them, so they can’t be made topical or given in pill form.

Is there a possibility that one can develop an immunity to Dupixent after long-term use of it?

We don’t have enough long-term data to understand if some people on Dupixent will have long-term benefits that continue after they go off the drug. Some flare quickly after stopping, while others can be off the drug for months and continue to do well.

We have no way to predict this, and since most patients on Dupixent have a long history of more severe eczema, we largely encourage people who are responding to Dupixent to stay on the medication. It will be interesting when we have more experience in children to see if Dupixent can modify the history of the eczema (that is, possibly cure it) or the risk of developing allergic conditions like asthma or hay fever if given much earlier in life before it becomes chronic.

Amy Paller, MD, chair of the department of dermatology at Northwestern University Feinberg School of Medicine and pediatric dermatologist at the Ann and Robert H. Lurie Children’s Hospital of Chicago

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