In this episode of Topical Conversations, Drs. James Q. Del Rosso and Lisa Swanson explore the concept of the atopic march and the critical importance of early intervention in atopic dermatitis (AD). They discuss strategies for addressing AD in young patients, the potential to prevent progression to other atopic comorbidities, and how to navigate conversations with parents about treatment options.
Understanding the atopic march
Dr Swanson highlights that atopic dermatitis often marks the starting point of the atopic march, a progression that can lead to other atopic conditions such as food allergies, asthma, and allergic rhinitis. While genetics lay the foundation, environmental factors, the skin and gut microbiomes, and skin barrier dysfunction can trigger the cascade of events that lead to AD and other atopic diseases.
Recent studies suggest a connection between AD and food allergies, pointing to how a compromised skin barrier allows aerosolized food particles to interact with the immune system abnormally.
The role of skin care in mitigating the atopic march
Dr Del Rosso acknowledges that evidence is limited regarding whether early skin care can prevent the atopic march, but he strongly advocates for measures that protect and restore the skin barrier. He emphasizes controlling environmental exposures, reducing the use of fragranced products, and promoting the use of sensitive skin care products.
Dr Swanson reinforces the importance of explaining the dual nature of AD to parents:
By framing treatment as a 2-pronged approach—nurturing the skin barrier with appropriate products and calming inflammation with medications—Dr Swanson finds parents better understand the importance of adherence to the treatment plan.
The potential of systemic therapies to alter the atopic march
Both Dr Swanson and Dr Del Rosso discuss the emerging evidence supporting the use of systemic therapies, particularly dupilumab, in young patients with AD. Dupilumab, which targets type 2 inflammation, has demonstrated effectiveness in not only treating AD but potentially reducing the risk of other atopic conditions, including asthma and food allergies.
Dr Swanson shares a case of a 6-month-old with moderate AD. After initially treating with topicals, she introduced the idea of dupilumab to the family, citing data suggesting its ability to reduce the impact of atopic comorbidities. While the initial treatment improved symptoms slightly, the family ultimately decided to proceed with dupilumab, with Dr Swanson emphasizing its potential long-term benefits.
Dr Del Rosso agrees, referencing data that suggests dupilumab may lessen the severity of asthma or allergic sinusitis if used early. However, he notes the need for more robust long-term studies to confirm these findings.
Navigating conversations with parents
Introducing systemic treatments such as dupilumab to families can be challenging, particularly when injectables are perceived as more “severe” than topical or oral treatments. Dr Swanson advises a gradual approach:
Dr Swanson notes her frustration with the minimization of AD’s impact, particularly by primary care providers who may suggest children will "outgrow" the condition. While this may be true in some cases, she emphasizes that appropriate management is critical to improving their quality of life and mitigating future risks.
The unanswered question: how early should we intervene?
One outstanding question is how early intervention must occur to have a meaningful impact on the atopic march. While some data on dupilumab and early skin care are encouraging, definitive answers have not been established.
Dr Del Rosso acknowledges the difficulty in balancing the immediate concerns of parents with the long-term goals of preventing atopic comorbidities, given the lack of long-term studies. However, both he and Dr Swanson agree that early and aggressive management of AD is essential, even if the full extent of its benefits is not yet fully understood.
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.