Durability Matters in Atopic Dermatitis: Thinking Beyond Short-Term Response

In this episode of Topical Conversations, Dawn Merritt, DO, sits down with Naiem Issa, MD, to explore how dermatologists think about managing atopic dermatitis (AD) over years, not weeks. Their discussion centers on durability, consistency, and the patient experience, and how those factors shape treatment decisions in real-world practice. Using therapies such as tralokinumab as reference points, they examine what sustainable disease control truly looks like for chronic inflammatory disease.

Thinking beyond short-term endpoints

When asked what matters most when choosing a therapy for AD, Dr Issa reflects on the tension between modern expectations for rapid improvement and the long-term nature of chronic inflammatory disease. While regulatory pathways emphasize short-term endpoints to determine whether a drug moves forward, the clinical reality is that patients often require treatment over the long haul.

Early improvement is important, but Dr Issa emphasizes that lack of immediate response does not necessarily signal failure. Given the chronicity and complexity of AD, there are situations where allowing more time on therapy is appropriate, particularly when the treatment is well tolerated.

Setting expectations for a chronic disease

Dr Merritt highlights the importance of patient education and expectation-setting, particularly for individuals who have previously relied on fast-acting but unsustainable options such as steroids.  

Both clinicians stress the need to reframe the conversation. AD is not curable; it must be managed. The goal is to identify therapies that are safe and effective over time, rather than those that simply offer rapid but temporary relief.

Explaining the biology to support patience

Dr Issa notes that bringing biology into the conversation can help patients understand why durability matters. Rather than “setting off an atomic bomb” on the immune system, modern systemic therapies aim to target specific pathways involved in disease pathophysiology.

Helping patients understand that targeted immunomodulation works differentlyand can make waiting feel like a purposeful investment rather than a setback.

Why IL-13 inhibition may matter for long-term control

The conversation then turns to treatment selection, with a focus on IL-13 inhibition. Dr Issa explains that while IL-4 has long been recognized as part of AD pathophysiology, growing evidence suggests IL-13 plays a central role in driving disease.

With direct IL-13 blockade, clinicians may avoid some of the effects observed with therapies that inhibit both IL-4 and IL-13. Dr Issa references clinical experience and published cases in which patients switching from IL-4 blockade to tralokinumab experienced resolution of arthralgias. He also discusses head and neck dermatitis, including instances of de novo head and neck involvement reported with certain therapies, which can influence treatment choice when considering holistic patient care.

Avoiding unnecessary treatment switching

Dr Merritt notes that clinicians can sometimes be too quick to switch therapies in response to flares or adverse events. Frequent switching may introduce additional risk and uncertainty without improving long-term outcomes.

Dr Issa describes his approach as selecting therapies early that are designed for sustainability. The goal is to reduce risk while optimizing results in a single, cohesive strategy. In his clinical experience, tralokinumab has the potential to support this approach, including for patients who require a switch from another biologic.

The role of dosing flexibility in long-term adherence

Drawing from her own practice, Dr Merritt shares that patients who remain on tralokinumab through the initial 16 weeks may transition to once-monthly dosing. While the concept of long-term therapy can initially be difficult for patients to accept, the possibility of reduced dosing frequency can help ease concerns and improve adherence.

Dr Issa reinforces this point with clinical trial data, noting that patients who transitioned from every-2-week dosing to every-4-week dosing after 16 weeks maintained similar efficacy. He further highlights data showing that a subset of patients who discontinued therapy maintained clear or almost clear skin, or achieved EASI-75, for the remainder of the year.

He frames this as a practical question for patients: if there were a 1-in-4 chance of maintaining control after stopping therapy, would that be worth it? Dr Merritt notes that, in her experience, most patients would accept those odds.

Building a plan for the long term

The discussion concludes with a shared emphasis on early selection of therapies that balance efficacy, tolerability, and durability. Lowering the risk of adverse events, minimizing unnecessary switching, and giving patients a realistic path toward long-term control, including the possibility of dose reduction or sustained remission, are central to this approach.

The clinicians end by emphasizing that durability is not just a clinical endpoint; it is a strategy that supports better outcomes, better patient relationships, and more sustainable management of chronic inflammatory disease.

Key takeaways

• Atopic dermatitis requires long-term management, not short-term thinking
• Early efficacy matters, but durability and tolerability often matter more over time
• Setting realistic expectations helps patients stay engaged with chronic disease therapy
• Avoiding unnecessary treatment switching can reduce risk and improve continuity of care
• Dosing flexibility and the potential for sustained control can improve patient acceptance and adherence