Targeting Type 2: An extended look at dupilumab for AD, PN, BP, and CSU

In this extended cut of The Spot Check, new host Jamie Restivo, MPAS, PA-C, welcomes Andrew Mastro, MS, PA-C, for a deep and dynamic conversation centered on dupilumab and its broadening role in dermatologic care.  Together, they unpack the science behind type 2 inflammation and the mechanisms that make dupilumab effective across eight FDA-approved indications, including atopic dermatitis, asthma, chronic rhinosinusitis with nasal polyps, eosinophilic esophagitis, prurigo nodularis, bullous pemphigoid, and chronic spontaneous urticaria (CSU). Mastro offers a practical breakdown of type 2 cytokine activity and discusses how targeting these pathways drives disease control across skin, lung, and GI conditions.  The pair discuss first-line use of dupilumab in AD, emphasizing its safety profile, FDA approval down to 6 month of age, and ability to treat multiple comorbidities. They also explore new territory with bullous pemphigoid, reviewing data from the ADEPT trial, the challenges of oral corticosteroids in elderly patients, and how dupilumab might offer a safer, targeted alternative.  Mastro shares thoughtful insights on treating prurigo nodularis, advocating for aggressive, empathetic care and cautioning clinicians not to delay treatment as a biopsy is not necessary to make this diagnosis. He stresses the importance of documenting thoroughly and recognizing PN even in the absence of nodules.  The episode concludes with a discussion on chronic spontaneous urticaria (CSU), including diagnostic criteria, evolving treatment approaches, and patient expectations. They push back on outdated, exhaustive lab workups and advocate for focused history-taking and up-dosing antihistamines before initiating biologic therapy.  With clinical pearls throughout—including how to frame conversations with patients about long-term therapy, how to document for coverage, and when to lead with systemic options—this extensive conversation offers a masterclass in therapeutic decision-making, delivered with humor, heart, and high-level clinical insight.