Spotting the Systemic Candidate: Rethinking Treatment Goals in Atopic Dermatitis

In this episode of Topical Conversations, Nicholas Brownstone, MD, is joined by Peter Lio, MD, for a candid fireside chat on systemic therapies for atopic dermatitis (AD). Together, they explore why these treatments remain underutilized, how dermatologists can better identify systemic candidates, and what expanding therapeutic options mean for personalized patient care.

Why systemic therapy remains underused

Dr Lio emphasizes that dermatology has only had FDA-approved systemic options for AD for about a decade. Before that, therapies were mostly off-label and carried significant safety concerns. Despite advances, hesitation persists, often due to lingering perceptions of systemics as high-risk. While topical therapies remain foundational, Dr Lio argues that dermatologists should raise their expectations: improvement alone is not enough if patients still struggle with sleep, concentration, or recurrent flares.

Recognizing candidates for systemic therapy

Systemic therapy candidacy extends beyond visible lesions. Dr Brownstone stresses the importance of a full history and physical exam, while Dr Lio highlights tools such as the Atopic Dermatitis Control Tool to uncover quality-of-life impairments that might otherwise be missed. Sensitive areas, such as the face and hands, can also justify systemic consideration even in patients who appear mild or moderate by standard measures.

Overcoming hesitation and leveraging biologics

Traditional systemic agents like methotrexate or cyclosporine created a culture of caution due to safety concerns. Today’s biologics for atopic dermatitis (dupilumab, lebrikizumab, tralokinumab, and nemolizumab) offer safer, more convenient alternatives. Dr Lio notes that all are effective and generally well tolerated, with subtle differences in efficacy, speed of response, and side effect profiles that can guide treatment selection. Importantly, dermatologists can reassure patients about the possibility of dose spacing or eventual pauses once durable control is achieved.

Looking ahead: patient-centered goals

Both dermatologists agree that systemic therapy allows for elevated treatment targets, shifting from “good enough” improvement to clear skin and normalized quality of life. Positive patient experiences with systemic therapies build trust, improve adherence, and empower dermatologists to offer individualized care strategies.

Key takeaways

• Systemic underuse: Despite multiple safe and efficacious systemic agents now approved, many patients with AD patients remain undertreated; dermatologists should consider whether their patients’ disease burden justifies escalation
• Recognizing systemic candidates: Look beyond objective scores; QoL measures and disease location matter.
• Biologics today: Modern systemic therapies are safe, effective, and more convenient than older options
• Personalized treatment choices: Each biologic offers unique attributes that can be tailored to patient needs
• Treatment flexibility: Dose spacing or temporary pauses may be possible in well-controlled patients