Atopic dermatitis (AD) rarely holds still long enough to be neatly defined. A patient can look manageable one week and unravel the next. The visible disease comes and goes, but the underlying biology does not. That mismatch between what we see and what is actually unfolding is where much of the challenge in treating AD lives.

In a recent conversation, David Rosmarin, MD, Vice Chair of Education and Research at Tufts Medical Center, and Mary Gail Mercurio, MD, Professor in the Department of Dermatology at the University of Rochester Medical Center, return to a question that feels deceptively simple: when is it time to move beyond topicals?  

The answer, as they make clear, is less about a threshold and more about a shift in thinking. There was a time when systemic therapy felt like escalation, a last step after topicals had been exhausted, and disease had declared itself severe in a way that was easy to measure.  

“The threshold for switching to systemic dupilumab is certainly getting lower,” Dr Mercurio notes, pointing to growing confidence in both the safety and the breadth of use across indications.  

Part of that confidence comes from familiarity, part from data, and part from something more practical. Patients themselves are less hesitant when they understand where else a therapy is being used. The fact that dupilumab is now approved across multiple conditions, and down to six months of age, changes the conversation. Type 2 inflammation does not confine itself to a single diagnosis.

Treating the Disease You Don’t See

Even so, decisions aren’t made on biology alone. Clinicians are still working with approximations like body surface area, symptom severity, the patient’s description of itch. But what surfaces in this conversation is what actually drives many treatment decisions: disruption to quality of life.

Is the patient sleeping? Are they functioning during the day? Is the disease shaping how they move through their life? “I find that very helpful,” Dr Mercurio says of documenting impact alongside extent.  

A patient with limited BSA involvement can still be profoundly affected if the disease sits on the face or hands. Coverage decisions may hinge on those details, but more importantly, so should treatment decisions. AD can create the illusion of intermittence; a flare resolves, and for a moment, it feels like control has been restored. But the underlying inflammation remains.

A partial response may be enough to continue, or no response at all may prompt a change. “It really depends on that initial trajectory,” Dr Rosmarin says.  

The Reality of Imperfect Control

Even with effective systemic therapy, residual disease lingers. The need for adjunctive topicals becomes more targeted. Steroids, non-steroidals, and sometimes phototherapy when accessible can be layered in response to location, severity, and patient preference.  

No regimen is universal, nor outcome absolute; and access, as always, shapes what is possible. Phototherapy, for example, remains clinically valuable but financially out of reach for many patients. So, treatment must become a negotiation between ideal and realistically feasible.

“You always treat patients, not diseases,” they say. A platitude perhaps but repeated in the context of AD; it could not be more literal.

A Different Kind of Decision

There is no single version of this disease. Not in how it presents, affects daily life, or responds to treatment. A patient who tolerates partial control may be managed differently from one whose disease, even if limited, disrupts sleep, work, or self-image. The question lies in what kind of control we are willing to accept, and for whom.

Drs Mercurio and Rosmarin turn toward what’s coming next: JAK inhibitors, emerging pathways, new mechanisms that continue to expand what is possible; but the more meaningful shift may already be here.

We are deciding when to acknowledge that disease is systemic and what to do once we do. For a condition that rarely behaves consistently, that may be the most important change of all.

Related:  
Topical Conversations – Dupilumab in Practice: Navigating Use Across Clinical Scenarios