Treatment options for moderate and severe atopic dermatitis, and when to use what

In this interview with dvm360, Jason B. Pieper, DVM, MS, DACVD, assistant professor at Iowa State University goes in depth about the various treatment options for moderate and severe atopic dermatitis. Pieper outlines the various agents and therapies that should be used for moderate cases versus severe cases, explaining the advantages and disadvantages of the therapies, and specific cases in which one treatment is preferred over another, or discouraged. In his discussion, he talks about Janus kinase (JAK) inhibitors, cyclosporin, Cytopoint, allergen-specific immunotherapy, monotherapy, steroids, and more.

Click here to listen to an earlier part of Pieper’s interview, where he talks about treatment options for mild cases of atopic dermatitis.

Below is a partial transcript which has been edited for clarity.

Jason B. Pieper, DVM, MS, DACVD: For moderate, you know, that's kind of where you get to about the 5 to 6 categories. Those are kind of where I think of more of the drugs that are targeted towards, you know, atopic dermatitis. So, we have a variety of them. Realistically, you go looking at Cytopoint, which is the monoclonal antibody to [interleukin 31] IL-31, which is [an] injectable, canonized as well I should say, so it's only for dogs. I think it works really well. It's variable how long it works. You know, anywhere from 4 to 8 weeks can be successful for that and the nice thing is, you take out the compliance from the owner. It's an injectable you give there at the clinic and it's going to be good as far as that timeline, and you don't have to worry about the owner missing pills or not giving drugs or something like that.

Next kind of category I usually think of is kind of your Jak inhibitors. So the Jak inhibitors, would include both Apoquel, as well as Zenrelia. There's a little bit of differences between the two. Obviously, Apoquel has been out quite a while for that drug, and pretty successful, as far as, you know, how long it's been out—anywhere from 60% to 80%, I think it depends on how severe the disease is for [the] success rate for those. But it has been highly successful, relatively safe I would say for the most part, little bit of side effects here and there, but overall, I think it's relatively safe.

Zenrelia is a newer drug. I mean, it was approved by the FDA in September 2024. The biggest concern with it is it does have a black box warning around vaccinations and suppression and whatnot, but they've done some further studies with vaccination, showing that dogs that have previously been vaccinated and are getting then booster vaccines are easily able to achieve tighter levels for the distemper and rabies vaccine. And those were done in much larger studies: 4 times the quantity of dogs [than in] the initial study…. So, from that aspect, I think it's very safe—I'm not worried about the vaccines aspect with them. I think it's relatively safe there. Side effects, since it's also in kind of that Jak inhibitor category and kind of that same first generation of them, I believe that the side effects are relatively low. I have yet to see a side effect with those dogs either. So, I think it's same category for them.

Obviously, we always have steroids. Steroids work well, you know I kind of consider all 4 of those drugs as fast acting, and steroids are kind of in there. Steroids are like a silver bullet. They're highly successful, but long term, my absolute last option because of the side effects and you're definitely going to cause some health issues long term.