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
In this 45-minute symposium, expert faculty cover the latest updates for JAK inhibitors, including head-to-head efficacy and safety data for JAK inhibitors and biologics, and share clinical pearls for using JAK inhibitors in dermatology practice for atopic dermatitis."I can say that in my clinic, I am reaching for those high bars. You have toput yourself in the position of the patient or imagine that patient is your family member. Would you want mediocre treatment for them or average treatment or moderate treatment? You’d want them to get the best possible treatment. In my practice I’m now counseling patients 'yes we want clear skin. Yes, we want minimal itch. Yes we want your skin pain gone and for you to sleep better.'”- David Cotter, MD, PhDFC25: Charting the Course to Higher Targets With JAK Inhibition in Atopic Dermatitis: An Online ActivityThis activity is supported by an educational grant from AbbVie.
Don’t miss this Satellite Symposium from the 2025 Fall Clinical Dermatology Conference®, as Dr. Alexandra Golant, Dr. Mona Shahriari, and Dr. G. Michael Lewitt discuss IL-13 targeting biologics in the treatment of atopic dermatitis as well as strategies for optimizing their use.“To me, coming into an exam room in 2025, when we have so many different treatment options for these patients, it's a unique opportunity to use what we know about the data of these therapeutics and walk patients though their options and how to understand their disease state, and how to best choose the therapy that feels right for them.” – Alexandra Golant, MD FC25: Illuminate the Role of IL-13 Inhibitors for the Management of Atopic DermatitisThis activity is supported by an educational grant from Lilly.
“Of course we’re always starting with our basics: we’re using our gentle cleansers, our moisturization, our avoidance of known allergens or triggers, and then we're doing our topicals. But it can be very difficult if you have heavy stuff on your face or you’re required to put it on over and over. It can be really tough. So this paves the way really nicely to say it is time to move up, it is time to think about the next level, and typically the next step up is going to be a biologic agent.” - Peter Lio, MDA ‘HowTo’ activity delivers a short burst of engaging and compact content for learners to study at their own convenience. This microlearning activity is intended to provide practical insights from two experts on ‘HowTo’ improve care in head and neck atopic dermatitis in 10 minutes.This activity is supported by an educational grant from LEO Pharma.
This 30-minute symposium from the 2025 Pediatrics360 Virtual Conference takes a closer look at biologic therapies that can address the immune pathophysiology, associated comorbidities, and progression of moderate-to-severe atopic dermatitis in pediatric patients.“A lot of them (children with atopic dermatitis) do have tactile sensitivities and don’t like the way any creams, ointments, anything, feel on their skin. Thinking about a shot, even though it hurts, doing a shot once or twice a month can actually often be so much easier than having the parents have to argue with the kid two to three times a day to get the topicals on. So, I actually think of injections very quickly for patients with tactile sensitivities.” – Dr. Elizabeth SwansonPEDS25: Controlling the Wolf in Sheep’s Clothing: Managing Pediatric Atopic Dermatitis with Biologic Therapies: An Online ActivityThis activity is supported by an educational grant from Sanofi and Regeneron Pharmaceuticals, Inc.