Peter Foley

Atopic dermatitis (AD) is a chronic relapsing inflammatory skin disease estimated to affect approximately 30% of children and 10%–15% of adults in Australia. Of those with this condition, one in five is estimated to have moderate‐to‐severe disease. Treatment guidelines for patients with moderate‐to‐severe AD recommend adding or switching to a targeted systemic medication if the disease is not well controlled with topical treatment. Without access to these medications, healthcare providers are limited in their ability to effectively treat moderate‐to‐severe AD. Availability of these guideline‐recommended targeted systemic agents varies across the globe because of differences in both approval and reimbursement decisions. Patients in Australia should have funded or subsidised access to these highly effective, well‐tolerated medications for moderate‐to‐severe AD. To highlight the importance of this, and to better understand potential barriers to such access in Australia, we conducted a narrative review of health technology assessment processes and the availability of funded/subsidised targeted systemic therapies for moderate‐to‐severe AD in patients aged ≥ 12 years in Australia and in countries with comparable healthcare systems, such as the United Kingdom, Canada, New Zealand and France. To provide context for this, we summarised current international guideline‐recommended treatment for moderate‐to‐severe AD and considered healthcare resource utilisation in moderate‐to‐severe AD, both in Australia and internationally. In Australia, patients only have access to a limited selection of medicines launched globally. This suggests that national healthcare systems should consider updating health technology assessment procedures to better align with the current targeted high‐cost therapeutics environment.

Actinic prurigo (AP) is a rare, idiopathic, acquired photodermatosis predominantly affecting indigenous populations in North, Central and South America. It is characterised by intensely pruritic papules and nodules on sun‐exposed skin, with potential involvement of the lips and conjunctivae. Treatment options are limited and often ineffective or associated with an unacceptable safety profile. This systematic review evaluates the existing evidence on the use of dupilumab and Janus kinase (JAK) inhibitors for AP management. A literature search was performed in MEDLINE, Google Scholar, ScienceDirect and Embase, for English‐language publications mentioning the use of dupilumab or JAK inhibitors for AP. Eligible studies included case reports, case series, observational studies, clinical trials, consensus statements and guidelines. Two independent reviewers assessed the manuscripts. The search yielded 125 results, with seven publications meeting eligibility criteria, comprising six case reports and one case series. Four publications described three patients successfully treated with dupilumab, demonstrating significant improvement within weeks of initiation. Three reports detailed the successful use of the JAK inhibitors tofacitinib and baricitinib in three patients, leading to rapid symptom resolution. Emerging evidence suggests that dupilumab and JAK inhibitors may be effective in AP treatment. Evidence is limited to case reports with short follow‐up durations. Further studies are necessary to establish the efficacy, safety and long‐term outcomes of these novel therapies.

Real‐world use of dupilumab has unveiled a spectrum of side effects that were not fully appreciated in initial clinical trials. While dupilumab remains a highly effective treatment for atopic dermatitis, clinicians must be aware of real‐world adverse effects including ocular complications, inflammatory arthritis, psoriasiform eruptions and head and neck dermatitis; as well as reported associations including cutaneous T‐cell lymphoma, alopecia areata, vitiligo and weight gain.

This retrospective analysis of Hedgehog inhibitor treatment in 32 patients with Gorlin syndrome, locally advanced and metastatic basal cell carcinoma (BCC) at three tertiary referral centres in Victoria, Australia from April 2017 until 30 June 2024 demonstrated an 84% overall objective response rate (partial and complete response combined). However, 90% of patients experienced adverse effects impacting quality of life. Secondary acquired drug resistance occurred in 77% (10/13) of locally advanced and metastatic BCC patients after a median duration of 13 months. Further work is needed to optimise the neoadjuvant use of Hedgehog inhibitors with radiotherapy or surgery given poor long‐term Hedgehog inhibitor tolerability and to develop strategies to counteract the issue of acquired resistance.

With its chronicity and varied symptomatology, moderate to severe atopic dermatitis (AD) remains a significant challenge for both patients and health care professionals. Novel targeted therapies, including the JAK inhibitors (JAKi) offer significant hope. There are many systematic reviews and meta‐analyses of the use of JAKi for the management of atopic dermatitis, but few offer practical advice for the clinician. The aim of this consensus development was to place the current literature for JAKi use in atopic dermatitis within the clinical context of practice in Australasia. The Australasian Medical Dermatology Group (AMDG) reviewed the evidence for the use of JAKi in the management landscape of atopic dermatitis, adding in their cumulative experience, and used an eDelphi process to agree on best practice. In the first round of 133 eDelphi clinical practice statements, consensus was achieved in 117 (88%—complete 27.8%, close 60.1%), with no consensus in 16 (12.0%) of the statements. The 16 clinical practice statements that did not reach consensus were reviewed and revised to 15 statements and then subjected to a second round: complete consensus was achieved in 5/15 statements, close consensus in 6/15, and no consensus in 4/15. Over the two eDelphi rounds, consensus was achieved in 128/132 (97%—complete 32%, close 64%) and no consensus in 4/132 (3%). Statements regarding screening for prior varicella infection, age‐appropriate cancer screening intervals, and management of flares did not reach full consensus. This study highlights areas where further research is needed to assist practicing dermatologists in safe prescribing and management of atopic dermatitis with JAK inhibitors.

Skin disorders rank sixth in the non‐fatal burden of disease within Australia and fourth worldwide. Despite this burden of disease for skin conditions, local data pertaining to the management, treatment, outcomes and quality of life of this patient group are limited. The Australasian Dermatology Registry will monitor and evaluate current and emerging therapies, provide real world evidence on the impact skin disorders have on patients living with these conditions and provide a platform for dermatology research.