From “Brown Bag Review” to Biologics: AD Care for 65+

In this episode of Topical Conversations, Daniel Butler, MD, joins Adam Friedman, MD, to focus on an often under-recognized group: older adults with atopic dermatitis (AD). They explore why late-onset AD after 65 is more common than many clinicians may assume, how pruritus frequently outpaces visible inflammation in this cohort, and therapeutic considerations when dexterity limits, comorbidities, and polypharmacy complicate care.

AD beyond childhood

Dr. Friedman recalls the “rule of 3” from training when it comes to patients with childhood-onset AD: one third improve over time, one third remain the same, one third worsen; he also notes that approximately 20% of adults develop AD de novo, including those ≥65. In susceptible patients, skin senescence, barrier decline, and pH shifts can tip genetics into clinical disease. He emphasizes that recognizing new-onset AD or AD-like phenotypes in older adults and identifying it correctly is essential.

Pruritus out of proportion

Drs Friedman and Butler then highlight age-related presentation differences: in older adults, AD often manifests as more papular, less scaly, truncal-predominant disease with pruritus out of proportion to modest visible inflammation. They emphasize that this itch–rash discordance can lead clinicians to underestimate disease burden and its impact on sleep, mood, and daily functioning.

Practical barriers: polypharmacy, access, application

They next discuss the importance of appropriately matching therapy to real-world constraints. They explain how polypharmacy can turn multistep topical regimens into the familiar “bag of creams” problem; twice-daily application may be unrealistic given mobility, reach, or vision limitations, and even injectables require assessing dexterity, comfort with needles, bruisability and infection risk, and the availability of caregiver support.

Choosing treatments that work for this population

Drs Butler and Friedman agree that modern biologics have been transformative for AD treatment, with minimal drug–drug interactions, simple dosing intervals, and strong antipruritic/anti-inflammatory effects often reducing the need for multiple topicals or daily pills. Conversely, off-label antipruritics like gabapentinoids and SSRIs may pose renal and sedation risks in older adults.

Closing pearls and “theranostics”

They conclude their discussion with some practical pearls for managing this population, commenting that marked itch with modest dermatitis warrants a thoughtful differential, considering conditions like nonbullous pemphigoid and malignancy-related pruritus. After excluding more serious conditions, targeted biologics like dupilumab, lebrikizumab, and nemolizumab can act as “theranostics,” with response supporting a type 2 endotype and a lack of response redirecting the workup. Although older adults were under-represented in pivotal trials, Dr Friedman closes by emphasizing that dermatologists can be confident in safety and effectiveness in practice for this population.

Key takeaways

• AD can begin after 65: don’t dismiss late-onset disease in older adults
• Itch may far exceed visible inflammation: prioritize patient-reported pruritus and its impact on quality of life
• Match regimen to reality: consider dexterity, vision, caregiver support, and polypharmacy
• Biologics can fit well for older adults: few interactions, interval dosing, strong itch and skin control
• Be cautious with off-label antipruritics: renal/sedation risks are higher in this group
• Use “theranostics “wisely: targeted biologic response can clarify the immunologic driver after serious causes are excluded