In this video blog, Dr. Jason Hawkes summarizes his lecture in the panel discussion, Challenging Cases in Atopic Dermatitis and Pruritus , on November 9, 2024, 5th Annual Elevate-Derm West Conference at the Westin Kierland Resort in Scottsdale, AZ.

In this video

Dr. Hawkes emphasizes that the first step with a dupilumab "non-responder" is distinguishing primary failure (no improvement from the outset) from secondary failure (an initial response that fades). A true primary failure prompts him to rethink the diagnosis — cutaneous T-cell lymphoma, a masked psoriasis case, or a drug reaction — since there is no biomarker to confirm AD. For patients with a partial or breakthrough response, he works to optimize before abandoning the drug: checking triggers, probing real-world steroid compliance, and layering non-steroidal topicals, while reserving a therapy switch for widespread, erythrodermic, or persistent head-and-neck disease.

On the CTCL concern raised by a recent retrospective study, he cautions that such analyses can't confirm what patients actually had, and points to two decades of lymphoma research showing that higher type 2 cytokines (IL-4/IL-13) correlate with CTCL progression — making it mechanistically implausible that blocking type 2 inflammation would drive it. He describes "clonal dermatitis" cases that convert over time, and notes the FDA label and EU review find no association. For lichen planus and prurigo nodularis, he favors targeted agents — dupilumab, nemolizumab (IL-31 receptor), and IL-13 inhibitors — over broader immunosuppressants and JAK inhibitors, citing better safety, tolerability, and fewer contraindications given these patients' comorbidities.

  • Separate dupilumab primary failures from secondary failures — a patient with no response from the start should trigger a diagnostic rethink (CTCL, psoriasis, drug reaction) since AD has no confirmatory biomarker.
  • For breakthrough flares on dupilumab, optimize first: address triggers, honestly assess steroid compliance, and add non-steroidal topicals before switching therapy — most patients are happy at 75–90% clearance.
  • The dupilumab–CTCL link rests on limited retrospective data; lymphoma research shows type 2 cytokines drive CTCL progression, and over a million treated patients plus FDA/EU review show no clear association.
  • Some early CTCL presents as "clonal dermatitis" without malignant features, with roughly 50% converting within a year — repeat biopsies when clinical suspicion is high.
  • For lichen planus and prurigo nodularis, targeted agents (dupilumab, nemolizumab, IL-13 inhibitors) are preferred first-line over JAK inhibitors given the comorbidity burden in these patients.