In this episode of Topical Conversations, Brad Glick, MD, and James Del Rosso, DO, discuss the delayed initiation of systemic treatments, particularly injectables for atopic dermatitis (AD). They explore the barriers both patients and providers face when considering advanced therapy, how to navigate conversations with patients, and where emerging biologics like lebrikizumab fit into the treatment landscape.
Shifting the conversation: helping patients understand systemic therapy
Many patients hesitate when the topic of systemic therapy is introduced, sometimes assuming that topicals alone should be sufficient. Dr Glick compares this to the early days of biologic therapy for psoriasis, noting that AD is not just a surface-level condition but rather one driven by internal inflammatory pathways.
When discussing treatment escalation with patients, he focuses on educating them about cytokines, explaining that they drive inflammation and itch, which topical treatments cannot fully address. He also reinforces the need for systemic intervention to patients by explaining that AD is often associated with systemic comorbidities, such as asthma, anxiety, depression, and sleep disturbances.
Why are so many dermatologists still hesitant?
Dr Glick notes that it’s not just patients who hesitate when it comes to systemic treatments, estimating that only 30% of dermatologists routinely prescribe systemic biologics for AD, raising the question: what’s holding back the other 70%?
He emphasizes that while biologic options like lebrikizumab (an IL-13 inhibitor) and dupilumab (an IL-4/IL-13 inhibitor) have excellent safety profiles, JAK inhibitors may have contributed to overall hesitation around systemic treatments among some providers.
Addressing topicals, Dr Del Rosso reiterates that they have a place in treatment but cannot address the root cause of AD in many patients. He notes that his threshold for initiating systemic therapy has become lower, given that patients with AD often experience significant itch and sleep disruption.
Drs Glick and Del Rosso compare AD to psoriasis and acne, questioning why it has been standard practice to wait until disease worsens before initiating advanced therapies. With new insights into the Th2 inflammatory pathways, they stress the need to proactively treat AD earlier with systemic therapies rather than relying on reactive treatment strategies.
Lebrikizumab: a unique addition to the ad treatment landscape?
With IL-13 inhibition recognized as a key target in AD, Dr Del Rosso asks whether lebrikizumab offers anything new or if it’s just another “me too” biologic.
Dr Glick highlights its distinct mechanism of action, explaining that while dupilumab blocks IL-4 and IL-13 via dual receptor inhibition, lebrikizumab selectively inhibits IL-13 by targeting the IL-13 alpha receptor, making it a particularly targeted therapy for AD.
Dr Del Rosso also points to long-term data showing that some patients maintain response even after stopping lebrikizumab, noting that this could offer more flexibility for patients who need to pause treatment due to insurance changes or travel without experiencing an immediate relapse. They compare this to oral systemic medications, which require daily dosing and can lead to quick relapse if stopped.
Addressing patient fears and misconceptions
Despite the strong safety profiles of modern biologics, Dr Glick acknowledges that patients still express fears about systemic treatments, often influenced by direct-to-consumer advertising for older psoriasis biologics with warnings about severe adverse events.
He advises his colleagues to differentiate AD biologics from older psoriasis therapies in discussions with patients and reassure them that IL-4, IL-13, and IL-31 inhibitors have well-characterized, predictable safety profiles.
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.