What Exactly Are Biologics for Eczema?
Biologics are a class of medication derived from living cells, rather than being chemically synthesized like traditional drugs. For eczema, also known as atopic dermatitis, biologics are genetically engineered proteins that act as monoclonal antibodies to target and block specific proteins in the immune system. This is a fundamentally different approach from older, broad-spectrum immunosuppressants or topical steroids, which treat general inflammation without the same level of specificity.
Unlike creams or pills, biologics are typically administered via injection. By targeting key inflammatory proteins, or 'interleukins,' that drive the inflammatory response in eczema, biologics can effectively calm the immune system and provide significant, long-lasting relief from symptoms like itchiness and skin lesions.
The Role of the Immune System in Eczema
Eczema is a complex inflammatory condition rooted in an overactive immune system. In atopic dermatitis, certain T-cells of the immune system produce chemical messengers called interleukins (ILs), including IL-4, IL-13, and IL-31. These proteins signal other immune cells to trigger an inflammatory response that damages the skin barrier and causes the intense itch and redness characteristic of eczema. By blocking these specific signaling proteins, biologics prevent the immune system from overreacting, addressing the condition's root cause from within.
Types of FDA-Approved Biologics for Eczema
There are several FDA-approved biologics for treating moderate-to-severe atopic dermatitis in the United States, with more in development. Each targets a specific inflammatory protein involved in the disease pathway.
- Dupilumab (Dupixent): This was the first biologic approved for eczema and is currently available for adults and children as young as 6 months of age with moderate-to-severe atopic dermatitis. It works by blocking both IL-4 and IL-13, which are key drivers of inflammation and skin barrier dysfunction.
- Tralokinumab (Adbry): Approved for use in adults and adolescents aged 12 and older, Adbry specifically targets and blocks IL-13.
- Lebrikizumab (Ebglyss): This biologic also targets IL-13 and is approved for individuals 12 years and older with moderate-to-severe atopic dermatitis.
- Nemolizumab (Nemluvio): A more recent addition, Nemluvio targets the IL-31 receptor, which plays a major role in the sensation of itch. It is approved for patients 12 years of age and older with moderate-to-severe atopic dermatitis.
How Biologics Are Administered
Biologics for eczema are taken via subcutaneous injection, meaning the medication is injected just under the skin. This is because the body's digestive system would break down the proteins in the medication, rendering it ineffective if taken orally. Most biologics are available as pre-filled pens or syringes, allowing patients or caregivers to administer them at home after receiving proper training from a healthcare provider.
- Loading dose: Treatment often begins with a higher initial dose to quickly reach a therapeutic level in the body.
- Maintenance dose: Following the loading dose, a regular schedule of injections is maintained, typically every two or four weeks, depending on the specific medication and patient.
Eligibility for Biologic Therapy
Biologics are generally not a first-line treatment for eczema. They are reserved for patients with moderate-to-severe atopic dermatitis who meet specific criteria, such as:
- Disease is not adequately controlled by topical therapies.
- Topical therapies are not advisable or effective for the patient.
- Certain age requirements are met (e.g., Dupixent for patients as young as 6 months; other biologics for patients 12 and older).
Biologics vs. Traditional Treatments: A Comparison
To understand the role of biologics, it is helpful to compare them to more traditional eczema treatments like topical corticosteroids.
| Feature | Biologics (e.g., Dupixent) | Topical Corticosteroids (Steroid Creams) |
|---|---|---|
| Mechanism of Action | Targeted; blocks specific inflammatory proteins (e.g., IL-4, IL-13) from within the body to calm the immune system. | Broad; reduces inflammation locally and non-specifically at the site of application. |
| Application Method | Subcutaneous injection, self-administered at home every few weeks. | Creams, ointments, or lotions applied directly to affected skin daily or multiple times per day. |
| Treats | Systemic disease affecting larger areas and the body's overall inflammatory response. | Localized symptoms and flare-ups on specific skin areas. |
| Long-Term Use | Intended for continuous, long-term use to manage the underlying disease and prevent flares. | Not recommended for long-term continuous use due to potential side effects like skin thinning. |
| Side Effects | Injection site reactions, conjunctivitis (pink eye), cold sores, and potentially increased risk of infections due to immune system changes. | Skin thinning, discoloration, stretch marks, and potential systemic absorption with long-term or high-potency use. |
Considerations and Side Effects
As with any medication, biologics carry potential risks and side effects. The side effects vary slightly between the different biologics but commonly include injection site reactions (redness, pain, swelling) and eye problems like conjunctivitis. Other, less common side effects are also possible, and it is crucial to discuss any medical history or concerns with a healthcare provider.
For example, Dupixent has been associated with eye and eyelid inflammation, redness, and itching. Allergic reactions, while rare, can also occur with any biologic. These are not typically considered broad immunosuppressants like older systemic medications, but they do alter the immune system and may increase the risk of certain infections. Blood tests may be required before starting some biologics, especially for individuals with a history of hepatitis B.
Cost and Affordability
Biologics for eczema are expensive to produce and can be costly for patients. Without insurance, the price can be thousands of dollars per month. However, most insurance plans, including commercial and government programs like Medicare, provide coverage. Additionally, pharmaceutical companies and non-profit organizations offer patient assistance programs and copay assistance to help eligible patients afford treatment. These programs can significantly reduce out-of-pocket costs, often to as little as $0 to $5 per month for commercially insured patients. For those on Medicare, different programs or alternative options may apply.
Conclusion
Biologics represent a modern, targeted approach to managing moderate-to-severe eczema by addressing the underlying inflammatory drivers of the disease. By calming the immune system in a specific way, they offer a powerful alternative for patients who have not found sufficient relief with topical treatments alone. With several FDA-approved options now available, patients can work with their dermatologist to determine the most suitable biologic based on their age, symptoms, and medical history. While continuous use is often needed, biologics have been shown to provide sustained relief and improved quality of life for many patients. For more detailed information on eczema management, you can consult resources like the National Eczema Association.
