Rapid resolution of refractory atopic dermatitis with abrocitinib: A case study focused on head and neck involvement

History, presentation and investigations
A Chinese man in his late 30s with a history of pulmonary tuberculosis, asthma, and nephritis, all in remission, presented to the clinic in November 2024 with worsening atopic dermati­tis (AD). He had previously used oral systemic steroids (up to 30 mg daily) and azathioprine (up to 100 mg dai­ly), with only mild response, leading to the discontinuation of these treat­ments.

Upon examination, the patient ex­hibited itchy, scaly red patches on his central face, ears, neck, upper trunk, and elbows, with significant erosions. The body surface area involvement was 50 percent. Laboratory work-up was negative for tuberculosis by QuantiFERON test, hepatitis B sur­face antigen, hepatitis core antibody, and hepatitis C antibody. His com­plete blood count was unremarkable except for elevated eosinophils at 10 percent, and he had mild dyslipidae­mia with LDL-cholesterol (LDL-C) at 3.16 mmol/L. Liver and renal function tests were normal.

Chest X-ray in 2022 revealed bi­lateral apical and right lateral horizon­tal fissure pleural thickening, and bi­lateral upper zone fibrotic changes. A CT scan of the thorax on 5 July 2024 showed a right upper lobe granulo­ma/nodule of 0.36 cm, bilateral api­cal, upper and mid-zone pleural thick­ening, and minor fibrotic changes.

Treatment and response
The patient was prescribed topi­cal clobetasol propionate lotion for his scalp, betamethasone dipropionate cream for his trunk and limbs, methyl­prednisolone aceponate cream for his face and neck, and 0.1 percent tacro­limus ointment for maintenance. While his body surface area involvement im­proved to 7 percent, he still had sig­nificant involvement of his central face despite more than 2 weeks of moder­ately potent topical steroid use.

After discussing systemic therapy options for his AD, including photo­therapy, conventional systemic im­munosuppressants, dupilumab, and Janus kinase inhibitors (JAKi), the pa­tient opted for JAKi.

He chose JAKi after weighing the risks, benefits, and cost of treatment. He found biologic treatment too ex­pensive and had suboptimal expe­riences with conventional systemic immunosuppressants in the past. The risks of worsening cholesterol levels and weakening immunity were explained. He also consulted a respi­ratory medicine specialist, and with a negative tuberculosis QuantiFER­ON test, he was deemed fit for JAKi treatment.¹

Oral abrocitinib 200 mg was ini­tiated, which produced a rapid and significant response after 2 weeks of treatment. (Figure) Mild dyspepsia initially occurred but subsided quickly with continued treatment.

Discussion
AD is a chronic inflammatory skin disorder characterized by relapsing episodes of pruritus, erythema, and skin barrier dysfunction.² The case presented illustrates a challenging instance of AD with significant in­volvement of the head and neck, a region often difficult to treat due to its sensitivity, cosmetic implications, and impact on quality of life.^3,4 Despite prior use of systemic steroids and azathioprine, the patient experienced only limited response, highlighting the need for a more targeted and effec­tive treatment approach.

Abrocitinib, an oral JAK1 inhibitor, has emerged as a promising thera­peutic option for moderate-to-severe AD. Its mechanism of action involves selective inhibition of JAK1, thereby reducing the activity of cytokines in­volved in the pathogenesis of AD, in­cluding interleukin (IL)-4 and IL-13.^1,5

In the phase III JADE COMPARE clinical trial, more patients on abroc­itinib 200 mg had significant itch reduction at 2 weeks (defined as ≥4-point improvement from baseline in Peak Pruritus Numerical Rating Scale [PP-NRS] score) compared with placebo (49.1 vs 13.8 percent).⁵ This highlights the effectiveness in quickly alleviating one of the most bothersome symptoms of AD.

Abrocitinib’s efficacy extends to difficult-to-treat areas, including the head and neck regions. In the JADE COMPARE trial, abrocitinib 200 mg achieved a shorter median time to ≥75 percent improvement in Eczema Area and Severity Index (EASI) in the head and neck areas compared with place­bo (29 vs 111 days).⁶ This rapid im­provement in such challenging areas underscores abrocitinib’s potential as a valuable treatment option for patients with AD who often struggle with symp­toms in these regions. For the patient described above, abrocitinib provided a rapid and significant improvement in symptoms, particularly in the head and neck regions, within 2 weeks of treat­ment initiation.

The head and neck pose unique challenges in AD management due to the thinness of the skin and its ex­posure to environmental irritants.^3,7 Furthermore, this area is prone to secondary infections, making it crit­ical to achieve effective control of inflammation and pruritus. Topical therapies, while effective for some patients, may be insufficient for se­vere or refractory cases.⁸ Moreover, prolonged use of topical steroids on the face can cause unwanted side effects such as cataract, glaucoma, rosacea, acne, and skin atrophy. ^9,10 This patient’s limited response to moderately potent topical steroids underscores the need for systemic therapy for severe AD.

Abrocitinib offers several advan­tages in the treatment of AD, partic­ularly for difficult-to-treat areas. Its rapid onset of action is of remark­able benefit, as demonstrated in this patient’s case, where significant improvement was observed within 2 weeks. This is consistent with the JADE COMPARE trial’s report of rap­id reductions in pruritus and lesion severity with abrocitinib.^5,6 Addition­ally, its oral administration provides a practical and patient-friendly al­ternative to injectables, which the above patient found cost-prohibitive. In cases which are stable, some of my patients have further reduced abrocitinib’s dosage to once ev­ery few days, thereby reducing the cost and potential side effects of the treatment.

While abrocitinib was well tol­erated in this case, it is essential to consider its safety profile, particularly in patients with a history of comor­bidities. This patient’s prior history of pulmonary tuberculosis and nephritis warranted a thorough evaluation be­fore initiation of therapy.¹ Negative tuberculosis QuantiFERON testing and clearance by a respiratory med­icine specialist ensured the safety of abrocitinib in this patient. Nonethe­less, clinicians should remain vigilant for potential adverse effects, including increased risk of infections, dyslipidae­mia, and gastrointestinal disturbances.¹ The mild dyspepsia experienced by the patient in this case resolved with con­tinued therapy, aligning with the gen­erally manageable side effect profile reported in JADE COMPARE.⁵

Another important consideration is the impact of JAKi on lipid me­tabolism. This patient had mild dys­lipidaemia, with an LDL-C level of 3.16 mmol/L, which necessitated care­ful monitoring during treatment.¹ While abrocitinib has been associated with alterations in lipid profiles, the clinical significance of these changes remains under investigation. Current guidelines recommend regular monitoring of lipid levels in patients receiving JAKi.^1,11-13 If the dyslipidaemia is mild, lifestyle modifi­cations, including exercise and diet mod­ification, may be all that is necessary. In the worst-case scenario, patients may need further medical evaluation to see if cholesterol-lowering medications are needed.^12,13

This case also highlights the im­portance of shared decision-making in the management of chronic con­ditions such as AD. The patient’s prior experiences with systemic immunosuppressants and financial constraints influenced his treatment choice. Abrocitinib provided an af­fordable and efficacious solution, demonstrating the importance of tai­loring treatment plans to individual patient’s needs and preferences.

Conclusion
In conclusion, abrocitinib rep­resents an effective treatment option that provides rapid improvement for refractory AD, particularly in chal­lenging regions such as the head and neck. This case underscores the importance of a comprehensive eval­uation and individualized treatment approach, including consideration of the patient’s comorbidities, pref­erences, and treatment goals. Fur­ther studies and long-term real-world data will be valuable in elucidating the full potential of abrocitinib in the management of AD.