Effective Treatments and Insights for Managing Type 2 Inflammation

Overview of the meeting

A recent second annual Horizons in Advanced Practice meeting in Tampa, Florida, convened advanced clinicians from around the country to review challenging cases in inflammatory skin disease and to discuss evolving treatment strategies.

The two-day program brought together physician assistants and nurse practitioners for expert-led breakout sessions focused on complex atopic dermatitis (AD), prurigo nodularis (PN), chronic spontaneous urticaria (CSU), psoriasis, chronic hand eczema, and hidradenitis suppurativa.

Breakout sessions and clinical framing

Dermatologist Omar Noor, MD, FAAD, co-owner of Rao Dermatology in New York and a member of an editorial advisory board, led the first half of the breakout sessions and walked attendees through representative, real-world patient cases centered on type 2 inflammation and modern targeted therapies.

Noor emphasized a broader view of eczema: “When you see that patient with AD, you look at them from a broader perspective to say, ‘Yes, I see your eczema, but we know this systemic component of this eczema is actually being driven by type 2 inflammation.’”

Case 1: A child with moderate to severe atopic dermatitis

The first case was a 10-year-old boy with long-standing moderate to severe AD affecting roughly 15% of his body surface area, with persistent flexural and facial involvement, severe itch, sleep disturbance, and significant psychosocial impact.

He also had comorbid allergic rhinitis, mild asthma, and a family history of atopy. Topical treatments and a trial of cyclosporine had not achieved sustained control.

After shared decision-making, the care team started weight-based dupilumab (Dupixent) given every 4 weeks, with close follow-up planned to track both clinical response and quality-of-life measures.

Noor highlighted longer-term data suggesting unexpected benefits beyond skin clearance: post hoc analyses of the phase 3 LIBERTY AD PEDS program show that children with moderate to severe AD may be shorter than peers without AD, and that initiation of dupilumab between ages 6 and 11 was associated with modest improvements in growth — roughly a 5% increase in height in the analyses presented (Source: Cork et al., LIBERTY AD PEDS trial NCT03345914).

To address parental concerns about injections, attendees shared practical counseling language. One clinician noted telling a mother, “He’s going to have 15 seconds of being uncomfortable. He can do 15 seconds. And then that means him not waking up with blood under his nails from itching.”

Case 2: Refractory prurigo nodularis

The second case involved a 54-year-old woman with a 3-year history of prurigo nodularis (PN) with intensely pruritic nodules on the arms, legs, and upper back, causing sleep loss, scarring, and emotional distress.

Her medical history included hypertension, hyperlipidemia, obesity, allergic rhinitis, and mild asthma. Multiple topical and systemic treatments had produced limited benefit.

Because of the refractory nature of her disease and severe chronic itch, the team chose to start dupilumab with a 600 mg loading dose followed by 300 mg every 2 weeks.

Noor reviewed how treatment selection in PN often reflects the patient’s broader inflammatory profile: both dupilumab and nemolizumab (Nemluvio) have evidence of efficacy for PN, but choice can hinge on comorbidities and patient preferences.

Specifically, when PN occurs in the context of overlapping type 2 conditions such as AD or asthma, clinicians tend to favor dupilumab because it addresses the shared inflammatory pathway and multiple symptoms. For patients with isolated PN or who are needle-averse and prefer fewer injections, nemolizumab may be an appropriate alternative (Source: Nemolizumab clinical program; Galderma).

An attendee summarized this approach: “If they have more type 2 inflammation, like eczema and rhinitis, I go more with dupilumab because it helps treat the whole picture. But if it’s just PN, I consider nemolizumab.”

Case 3: Chronic spontaneous urticaria resistant to standard therapy

The third case was a 46-year-old man with a 9-month history of chronic spontaneous urticaria (CSU), experiencing daily hives and recurrent angioedema of the lips and periorbital area, severe itch, and disrupted sleep.

His lesions resolved within hours but recurred daily without clear triggers. His history included childhood eczema, allergic rhinitis, and controlled hypertension.

Despite use of high-dose second-generation H1 antihistamines, intermittent corticosteroids, and a trial of omalizumab (Xolair), he continued to experience breakthrough urticaria and angioedema that impaired daily functioning.

Noor reviewed emerging clinical trial data evaluating targeted therapies for CSU that remains symptomatic despite antihistamines. In the phase 3 LIBERTY-CSU CUPID program, dupilumab reduced itch and hive severity in patients who had not previously received omalizumab (Source: Maurer et al., LIBERTY-CSU CUPID, NCT04180488).

He also discussed two phase 3 trials, REMIX-1 and REMIX-2, which evaluated the oral BTK inhibitor remibrutinib (Rhapsido) in antihistamine-refractory CSU; both trials showed significant improvement on a composite measure of itch and hives at week 12 (Source: Metz et al., REMIX-1 and REMIX-2, NCT05030311, NCT05032157).

Clinical themes and practical takeaways

Attendees left the sessions with several clear clinical themes that can guide practice in complex inflammatory dermatoses.

First, recognizing overlapping inflammatory mechanisms helps clinicians choose therapies that treat more than one condition at once; targeting shared type 2 inflammatory pathways can improve skin disease while also addressing respiratory or allergic comorbidities.

Second, biologic selection should be individualized to the patient’s overall disease phenotype: choose agents like dupilumab when there are multiple type 2 comorbidities, and consider alternatives such as nemolizumab for isolated PN or when injection frequency is a major concern.

Third, the treatment landscape for CSU is shifting beyond antihistamine-only strategies: targeted biologics and small molecules are moving management into dermatology and offering options for patients who do not respond to current standard therapies.

Fourth, for patients who are steroid-sensitive or have cardiometabolic risk factors, directing therapy at the underlying type 2 pathway provides a steroid-sparing approach with safer long-term disease control compared with repeated systemic corticosteroid exposure.

Practical counseling and shared decision-making

The meeting highlighted how frank conversations about benefits, risks, logistics, and tolerability are essential, especially when discussing injectables with children or adults who have injection anxiety.

Clinicians shared simple, practical framing to set expectations and reduce fear — for example, emphasizing short-lived injection discomfort and the longer-term benefits of reducing severe itch, sleep loss, and skin damage.

Shared decision-making also includes discussing the broader impact of treatment selection on comorbid conditions, the frequency of office visits or injections, insurance considerations, and patient lifestyle preferences.

Conclusion

As new data and approved agents expand treatment options across AD, PN, and CSU, clinicians increasingly have the tools to tailor therapy to each patient’s inflammatory profile and comorbid disease.

Targeted, type 2–focused therapies are widening the therapeutic window for patients with chronic, burdensome skin disease and offer alternatives that can reduce steroid exposure and improve overall quality of life.

Sources

1. Cork MJ, Thaçi D, Eichenfield LF, et al. Dupilumab safety and efficacy in a phase III open-label extension trial in children 6–11 years of age with severe atopic dermatitis. Dermatol Ther (Heidelb). 2023;13(11):2697–2719. doi:10.1007/s13555-023-01016-9 (Source: LIBERTY AD PEDS trial, NCT03345914).
2. Maurer M, Casale TB, Saini SS, et al. Dupilumab in patients with chronic spontaneous urticaria (LIBERTY-CSU CUPID): two randomized, double-blind, placebo-controlled, phase 3 trials. J Allergy Clin Immunol. (Source: LIBERTY-CSU CUPID trials, NCT04180488).
3. Metz M, Giménez-Arnau A, Hide M, et al.; REMIX-1 and REMIX-2 Investigators. Remibrutinib in chronic spontaneous urticaria. N Engl J Med. 2025;392(10):984–994. doi:10.1056/NEJMoa2408792 (Source: REMIX-1 NCT05030311 and REMIX-2 NCT05032157).
4. ClinicalTrials.gov. LIBERTY AD PEDS: Dupilumab in pediatric atopic dermatitis. NCT03345914. https://clinicaltrials.gov/ct2/show/NCT03345914 (accessed). (Source: ClinicalTrials.gov).
5. ClinicalTrials.gov. LIBERTY-CSU CUPID: Dupilumab in chronic spontaneous urticaria. NCT04180488. https://clinicaltrials.gov/ct2/show/NCT04180488 (accessed). (Source: ClinicalTrials.gov).
6. ClinicalTrials.gov. REMIX-1: Remibrutinib for chronic spontaneous urticaria. NCT05030311. https://clinicaltrials.gov/ct2/show/NCT05030311 (accessed). (Source: ClinicalTrials.gov).
7. ClinicalTrials.gov. REMIX-2: Remibrutinib for chronic spontaneous urticaria. NCT05032157. https://clinicaltrials.gov/ct2/show/NCT05032157 (accessed). (Source: ClinicalTrials.gov).
8. Product and manufacturer information: Dupilumab (Dupixent) — Sanofi and Regeneron; Nemolizumab (Nemluvio) — Galderma; Remibrutinib (Rhapsido) — Novartis; Omalizumab (Xolair) — Genentech. (Source: respective company prescribing information and press releases).