In this episode of Topical Conversations, Dr James Del Rosso and Dr Amy McMichael discuss the challenges of identifying candidates for systemic treatment of atopic dermatitis (AD), with a particular focus on patients with skin of color. They explore how AD presents differently in diverse populations, considerations for assessing disease severity, and the role of systemic therapies like lebrikizumab in improving patient outcomes.
Challenges in diagnosing atopic dermatitis in skin of color
Dr Del Rosso highlights a key challenge in evaluating AD severity in diverse populations—the reliance on erythema as a primary indicator of disease activity. Assessments often include the presence of redness; however, erythema can be subtle or difficult to detect in darker skin tones, making it essential for dermatologists to look beyond color-based cues.
Dr McMichael reinforces this by emphasizing tactile and symptomatic assessments. She advises dermatologists to train patients and caregivers not just to treat when skin appears red but also when it feels rough or textured. In some cases, violaceous changes may be more apparent than classic erythema. Additionally, symptoms like itching, irritation, and sleep disturbances can be critical indicators of disease severity, even when visible skin changes seem minimal.
Another diagnostic challenge is hidden or underreported disease involvement. Patients may initially present with localized symptoms, but a thorough full-body skin exam can reveal more extensive disease, particularly in skin folds, scalp, or diaper areas for pediatric patients. This is especially important when considering systemic therapy, as true body surface area involvement and diffuse itching patterns can help guide treatment decisions.
The impact of hyperpigmentation, hypopigmentation, and lichenification
They also discuss discuss postinflammatory pigmentary changes that frequently affect patients with skin of color: Hyperpigmentation, which often resolves over time but can be persistent and distressing for patients; hypopigmentation, which can be more challenging to treat, and if chronic, may not fully recover even after the underlying AD is controlled; and lichenification, which is a common long-term consequence of chronic AD in darker skin tones and can persist despite active treatment.
Dr McMichael emphasizes that chronic hypopigmentation resulting from prolonged scratching can cause lasting skin damage. While systemic treatments can control AD, they do not always restore lost pigment, making early and aggressive treatment crucial. Dr Del Rosso adds that hyperpigmentation tends to improve over time, but the contrast in skin tone can make these changes more noticeable and distressing for patients with darker skin.
Systemic therapy for atopic dermatitis: when to escalate treatment
Dr McMichael follows a stepwise approach when treating AD, usually beginning with topical treatments as the first-line therapy for mild-to-moderate cases. She then moves on to systemic agents for moderate-to-severe cases that are not adequately controlled with topicals.
She emphasizes escalating treatment quickly when necessary, particularly when AD affects daily life, including school performance, sports participation, and sleep quality. She highlights the importance of early treatment education, noting that patients and caregivers need to understand that AD is a chronic condition, not a disease with a simple cure.
The role of positive reinforcement in patient compliance
Dr McMichael stresses the importance of positive feedback in patient care. When patients or caregivers follow treatment plans diligently, acknowledging their efforts reinforces good habits. Encouraging words from a dermatologist can motivate patients to continue treatment, improving long-term outcomes.
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.