What is the best biologic treatment for asthma with atopic dermatitis?

Best Biologic for Asthma with Atopic Dermatitis

Dupilumab is the definitive first-line biologic choice for patients with both asthma and atopic dermatitis, as it is the only biologic with FDA approval and strong guideline recommendations for treating both conditions simultaneously. 1, 2

Why Dupilumab is Superior for Dual Disease

Dupilumab uniquely addresses both conditions through a single therapeutic mechanism by blocking the IL-4 receptor α subunit, thereby inhibiting both IL-4 and IL-13 signaling pathways that drive type 2 inflammation in both asthma and atopic dermatitis. 2, 3, 4

Dual FDA Indications

• Dupilumab is FDA-approved for moderate-to-severe atopic dermatitis in patients aged 6 months and older whose disease is inadequately controlled with topical therapies. 2
• Dupilumab is FDA-approved as add-on maintenance treatment for moderate-to-severe asthma in patients aged 6 years and older with an eosinophilic phenotype or oral corticosteroid-dependent asthma. 2
• No other biologic currently holds FDA approval for both conditions. 2

Guideline Support for Dual Disease Management

• The American Academy of Dermatology makes a strong recommendation for dupilumab as first-line systemic therapy for moderate-to-severe atopic dermatitis, with all surveyed guideline workgroup members favoring dupilumab over other options. 1, 5
• Expert consensus specifically identifies that patients with comorbid diseases and dual indications should be directed toward dupilumab, as it improves both atopic dermatitis and chronic rhinosinusitis with nasal polyposis (and by extension, asthma). 1
• The 2025 EUFOREA pocket guide recommends dupilumab for type 2 asthma, reinforcing its role in airway disease management. 1

Clinical Efficacy Profile

Atopic Dermatitis Outcomes

• Dupilumab achieves 63-64% of patients reaching EASI 75 (75% improvement in Eczema Area and Severity Index) at 16 weeks when combined with topical corticosteroids. 5
• Dupilumab demonstrates rapid and significant improvements in adults with moderate-to-severe atopic dermatitis with an excellent safety track record over more than 5 years in clinical practice. 1, 5

Asthma Outcomes

• Dupilumab significantly reduces asthma exacerbations, fractional exhaled nitric oxide (FeNO) levels, and oral corticosteroid requirements. 3, 4
• The drug effectively inhibits type 2 inflammation through its dual IL-4/IL-13 blockade mechanism. 4, 6

Dosing Regimen

Standard dupilumab dosing for adults with both conditions:

• Initial loading dose: 600 mg subcutaneously (administered as two 300 mg injections at different sites). 2
• Maintenance dose: 300 mg subcutaneously every 2 weeks. 1, 2

Safety Considerations and Management

Most Common Adverse Event: Conjunctivitis

• Conjunctivitis occurs in 6-15% of patients in clinical trials and up to 26.1% in real-world atopic dermatitis populations. 5
• Among asthma patients, conjunctivitis rates are lower but still present. 2

Management algorithm for ocular complications:

• Mild symptoms: Use preservative-free ocular lubricants and topical antihistamine eyedrops while continuing dupilumab. 5
• Moderate symptoms: Continue dupilumab while actively treating ocular symptoms. 5
• Severe symptoms or keratitis: Refer to ophthalmology for evaluation; consider discontinuation if refractory to ophthalmologic management. 5, 2

Other Safety Signals to Monitor

• Eosinophilic conditions: Monitor for eosinophilic pneumonia or eosinophilic granulomatosis with polyangiitis (EGPA), particularly when reducing oral corticosteroids. 2
• New-onset psoriasis: Rare cases reported; advise patients to report new skin lesions. 2
• Arthralgia: Monitor for joint symptoms; some cases have required hospitalization. 2

Alternative Biologics (Inferior for Dual Disease)

Why Other Biologics Are Not Optimal

Omalizumab:

• FDA-approved for allergic asthma but not for atopic dermatitis. 1
• Would require separate therapy for atopic dermatitis management. 1

Mepolizumab, Reslizumab, Benralizumab:

• Target IL-5 pathway for eosinophilic asthma but have no efficacy for atopic dermatitis. 1
• Would leave atopic dermatitis untreated. 1

Tralokinumab:

• FDA-approved for atopic dermatitis with strong recommendation from the American Academy of Dermatology. 1
• However, tralokinumab is not FDA-approved for asthma and is somewhat less effective than dupilumab for atopic dermatitis at 16 weeks. 1

Tezepelumab:

• Approved for severe asthma (type 2 and non-type 2) but not for atopic dermatitis. 1

Clinical Decision Algorithm

For patients with confirmed moderate-to-severe asthma AND moderate-to-severe atopic dermatitis:

1. First-line choice: Initiate dupilumab 600 mg loading dose, then 300 mg every 2 weeks. 1, 5, 2

2. Consider alternative only if:

   • Pre-existing severe ocular surface disease exists (use JAK inhibitor for atopic dermatitis instead). 5
   • Patient is female planning pregnancy (omalizumab for asthma, but separate atopic dermatitis therapy needed). 1
   • Dupilumab-related ocular disease is refractory to ophthalmologic management. 5

3. Continue topical therapies: Maintain topical corticosteroids and emollients for atopic dermatitis alongside dupilumab. 1, 2

4. Do not abruptly discontinue corticosteroids: Taper oral or inhaled corticosteroids gradually under physician supervision. 2

Common Pitfalls to Avoid

• Do not use separate biologics for each condition when dupilumab can treat both simultaneously. 1, 2
• Do not discontinue dupilumab prematurely for mild conjunctivitis; manage with lubricants and antihistamine drops first. 5, 2
• Do not use dupilumab for acute asthma exacerbations or bronchospasm; it is maintenance therapy only. 2
• Do not forget to assess for helminth infections before initiating therapy, as dupilumab may affect immune response to parasites. 2