Topical Conversations

As we continue to deepen understanding of the aryl hydrocarbon receptor (AhR), April Armstrong, MD, MPH, and Elizabeth (Lisa) Swanson, MD, explore why AhR has remained a relatively unfamiliar pathway for many clinicians despite years of clinical experience, and further, the relevance it has now. Together, they discuss AhR agonism as a distinct therapeutic approach, its role in immune regulation, skin barrier restoration, and oxidative stress, and how those biologic effects translate into practical treatment decisions. Along the way, they compare AhR with other topical mechanisms, share how their own prescribing has evolved, and look ahead to what this emerging therapeutic class may teach us about inflammatory skin disease beyond today's indications.

Safety, monitoring, and shared decision-making across biologic and adjunctive careIntegrative care in atopic dermatitis (AD) is not only about what clinicians may add to the treatment plan. It’s about how those recommendations are evaluated, monitored, and shaped around the person expected to follow them.In the final installment of this Topical Conversations series, Cynthia Trickett, PA-C, and Peter Lio, MD, turn to the practical responsibilities that come with combining adjunctive strategies and biologic therapy. Dr Lio discusses the long-term safety experience with biologics while emphasizing the importance of continuing to watch emerging signals with appropriate humility. The same caution extends to supplements, where ingredient quality, contamination, counterfeit products, and inconsistent manufacturing can make a seemingly straightforward recommendation far more complicated. When he does recommend a supplement, he tries to be highly specific about the brand and supplier.The conversation then moves from safety to sustainability. Gentle cleansing, regular moisturizing, reducing environmental irritants, sleep, nutrition, and movement may all support care, but only when they fit the patient’s life. A recommendation that is unaffordable, intolerable, inaccessible, or unrealistic is unlikely to succeed, no matter how sound it appears on paper.That reality also shapes follow-up. Dr Lio describes checking in early with patients who have more severe disease and using the Atopic Dermatitis Control Tool to move beyond a general sense of “better” toward a more structured assessment of whether the disease is truly controlled. Those conversations may reveal that a treatment was never received, not covered, caused stinging or burning, or simply did not fit into the patient’s routine.Ultimately, the episode returns to the foundation of integrative care: listening. “The goal is to get you better,” Dr Lio says. That means giving patients options, inviting them to guide the plan, and remaining flexible enough to adjust when one approach does not fit. Integrative care enhances biologic therapy rather than replacing it, creating a broader and more individualized path toward control.

Skin care, diet, supplements, probiotics, and microbiome-directed strategies in clinical contextAfter establishing why adjunctive strategies matter in atopic dermatitis care, Cynthia Trickett, PA-C, and Peter Lio, MD, turn to the practical questions clinicians hear constantly: Do natural oils have a role? How much does diet really matter? What about probiotics, vitamin D, hypochlorous sprays, or antimicrobial cleansers?For Dr Lio, skin care and barrier repair are so central to the biologic therapy treatment plan that he’s coined the term “Advanced Dermatologic Care,” or ADC, to describe the intentional use of OTC topicals, cleansers, moisturizers, written eczema action plans, and other supportive strategies that help patients and families understand what to do day to day and during flares. The conversation moves through natural oils, black tea compresses, diet myths, the risks of over-restriction, vitamin D supplementation, probiotics, and emerging microbiome-directed approaches, always returning to the same clinical foundation of evidence, safety, practicality, and individualized recommendations that support quality of life.Of the many adjunctive options patients may ask about, Dr Lio says, “part of our job is to try to filter them down into things that have some evidence, that are safe and are practical.” This discussion makes space for it all, and contextualizes what may be overstated, unproven, or potentially harmful. He reminds clinicians not to chase every trend, but to help build an adjunctive plan that protects the barrier, respects the microbiome, and avoids doing harm. Upcoming: In Part 3, Trickett and Dr Lio turn from what clinicians can add to how they can do it safely, with practical guidance on supplement quality, follow-up, treatment monitoring, and patient-led decision-making.

How complementary strategies can support biologic therapy without replacing evidence-based treatmentAtopic dermatitis (AD) care has changed dramatically in the biologic era, but better options have not eliminated the need for thoughtful adjunctive strategies. In this opening conversation, Cynthia Trickett, MPAS, PA-C, and Peter Lio, MD, begin with the clinical reality many dermatology providers know well: even when biologics are appropriate, effective, and well tolerated, patients may still need more support to control itch, inflammation, barrier dysfunction, sleep disruption, and the day-to-day burden of disease. As Dr Lio puts it, integrative care is not about replacing conventional medicine with “something crazy.” It is about “taking the best of both worlds and putting them together in a coordinated way.”Dr Lio outlines what integrative medicine can mean in AD, from mind-body approaches and botanicals to barrier support, microbiome-directed strategies, and other adjunctive tools that may help patients who are already using topical therapies or systemic agents. The conversation also grounds these approaches in the larger biologic landscape, including IL-4/IL-13, IL-13, and IL-31 pathway targeting, while acknowledging that these therapies, however transformative, are not perfect fits for every patient. Part 1 closes where clinical practice often begins—with the need to layer treatment thoughtfully, safely, and with the patient’s goals and comfort in mind.

There was a time when treating atopic dermatitis (AD) meant managing the peaks—calming a flare, then waiting for the next one to arrive. But as Elizabeth (Lisa) Swanson, MD, and E James Song, MD, describe, the disease doesn’t really turn off. AD settles, simmers, then resurfaces, more like a smoldering fire than something episodic. And once you start to see it that way, the goal becomes about stabilizing what’s happening over time instead of reacting to the moment.In this conversation, Drs Swanson and Song work through their approaches in clinic: lowering the threshold for biologics, rethinking what “controlled” actually means, and recognizing how much of the disease lives outside of what’s visible. The aim is getting patients off the rollercoaster, reducing the constant negotiation with their skin, and moving toward something steadier, more livable, and more honest to the disease itself.

In this episode of Topical Conversations, Dawn Merritt, DO, sits down with Naiem Issa, MD, to explore how dermatologists think about managing atopic dermatitis (AD) over years, not weeks. Their discussion centers on durability, consistency, and the patient experience, and how those factors shape treatment decisions in real-world practice. Using therapies such as tralokinumab as reference points, they examine what sustainable disease control truly looks like for chronic inflammatory disease.Thinking beyond short-term endpointsWhen asked what matters most when choosing a therapy for AD, Dr Issa reflects on the tension between modern expectations for rapid improvement and the long-term nature of chronic inflammatory disease. While regulatory pathways emphasize short-term endpoints to determine whether a drug moves forward, the clinical reality is that patients often require treatment over the long haul.Early improvement is important, but Dr Issa emphasizes that lack of immediate response does not necessarily signal failure. Given the chronicity and complexity of AD, there are situations where allowing more time on therapy is appropriate, particularly when the treatment is well tolerated.Setting expectations for a chronic diseaseDr Merritt highlights the importance of patient education and expectation-setting, particularly for individuals who have previously relied on fast-acting but unsustainable options such as steroids. Both clinicians stress the need to reframe the conversation. AD is not curable; it must be managed. The goal is to identify therapies that are safe and effective over time, rather than those that simply offer rapid but temporary relief.Explaining the biology to support patienceDr Issa notes that bringing biology into the conversation can help patients understand why durability matters. Rather than “setting off an atomic bomb” on the immune system, modern systemic therapies aim to target specific pathways involved in disease pathophysiology.Helping patients understand that targeted immunomodulation works differentlyand can make waiting feel like a purposeful investment rather than a setback.Why IL-13 inhibition may matter for long-term controlThe conversation then turns to treatment selection, with a focus on IL-13 inhibition. Dr Issa explains that while IL-4 has long been recognized as part of AD pathophysiology, growing evidence suggests IL-13 plays a central role in driving disease.With direct IL-13 blockade, clinicians may avoid some of the effects observed with therapies that inhibit both IL-4 and IL-13. Dr Issa references clinical experience and published cases in which patients switching from IL-4 blockade to tralokinumab experienced resolution of arthralgias. He also discusses head and neck dermatitis, including instances of de novo head and neck involvement reported with certain therapies, which can influence treatment choice when considering holistic patient care.Avoiding unnecessary treatment switchingDr Merritt notes that clinicians can sometimes be too quick to switch therapies in response to flares or adverse events. Frequent switching may introduce additional risk and uncertainty without improving long-term outcomes.Dr Issa describes his approach as selecting therapies early that are designed for sustainability. The goal is to reduce risk while optimizing results in a single, cohesive strategy. In his clinical experience, tralokinumab has the potential to support this approach, including for patients who require a switch from another biologic.The role of dosing flexibility in long-term adherenceDrawing from her own practice, Dr Merritt shares that patients who remain on tralokinumab through the initial 16 weeks may transition to once-monthly dosing. While the concept of long-term therapy can initially be difficult for patients to accept, the possibility of reduced dosing frequency can help ease concerns and improve adherence.Dr Issa reinforces this point with clinical trial data, noting that patients who transitioned from every-2-week dosing to every-4-week dosing after 16 weeks maintained similar efficacy. He further highlights data showing that a subset of patients who discontinued therapy maintained clear or almost clear skin, or achieved EASI-75, for the remainder of the year.He frames this as a practical question for patients: if there were a 1-in-4 chance of maintaining control after stopping therapy, would that be worth it? Dr Merritt notes that, in her experience, most patients would accept those odds.Building a plan for the long termThe discussion concludes with a shared emphasis on early selection of therapies that balance efficacy, tolerability, and durability. Lowering the risk of adverse events, minimizing unnecessary switching, and giving patients a realistic path toward long-term control, including the possibility of dose reduction or sustained remission, are central to this approach.The clinicians end by emphasizing that durability is not just a clinical endpoint; it is a strategy that supports better outcomes, better patient relationships, and more sustainable management of chronic inflammatory disease.Key takeawaysAtopic dermatitis requires long-term management, not short-term thinkingEarly efficacy matters, but durability and tolerability often matter more over timeSetting realistic expectations helps patients stay engaged with chronic disease therapyAvoiding unnecessary treatment switching can reduce risk and improve continuity of careDosing flexibility and the potential for sustained control can improve patient acceptance and adherence

In this episode of Topical Conversations, G. Michael Lewitt, MD, joins David Cotter, MD, to examine a common yet underrecognized challenge in atopic dermatitis (AD) management: how to care for patients who respond to systemic therapy but fall short of full clearance. The discussion focuses on identifying partial responders, optimizing ongoing treatment, determining when to adjust or transition therapies, and navigating conversations about realistic expectations and long-term disease control.Rethinking AD as a systemic diseaseDrs Lewitt and Cotter open the discussion by addressing a foundational challenge in AD care: helping patients understand that it’s not simply a “skin problem,” but a systemic inflammatory disease with diverse clinical expressions. He notes that conversations about systemics flow naturally from an assessment of severity, treatment goals, and disease impact. Patients often voice concerns about “immunosuppression,” and Dr Lewitt suggests reframing this as “immunomodulation” instead, helping patients understand mechanism, safety, and expected outcomes. He also stresses that severity assessment should not rely exclusively on Eczema Area and Severity Index scores or body surface area (BSA) affected; high-impact areas and patient-perceived burden often tip the scale toward systemic therapy.The role of topicals in a systemic eraAlthough systemic therapy is appropriate for many patients, Dr Cotter emphasizes that topical therapy remains central. Tapinarof, ruxolitinib, and other topical options can serve both as initial therapy and as “touch-up paint” during systemic treatment. He routinely checks whether partial responders have tapered or discontinued their topicals, an often-overlooked contributor to perceived loss of efficacy with systemics.Managing partial or nonrespondersThe clinicians then move into the core challenge: patients who respond incompletely or lose response over time.Dr Cotter describes his decision-making framework for adding, subtracting, or switching therapies. When patients improve but plateau (better itch control, reduced BSA, milder disease but persistent burden), he discusses next steps. Options include cycling biologics, switching classes, or transitioning to a small molecule. He highlights available evidence, particularly a head-to-head trial showing that patients with inadequate response to dupilumab were more likely to improve when switched to upadacitinib.Another strategy involves using a JAK inhibitor as a short-term “fire extinguisher” for severe flares or rapid symptom control, followed by a transition back to a biologic for long-term maintenance, a preferred option over prednisone in his practice.When patients want to stop systemic therapyA common scenario is the patient who feels markedly better and asks whether treatment can be discontinued. Dr Cotter frames this as “forever for now,” emphasizing patient autonomy while counseling on likely outcomes.He discusses differences by class:JAK inhibitors typically show loss of benefit within days of discontinuationSome biologics (lebrikizumab, dupilumab, tralokinumab) may allow a significant proportion of responders to maintain stable disease for up to a year off therapyBefore stopping outright, he often also negotiates dose interval extension (eg, dupilumab every 3 weeks instead of every 2; tralokinumab every 4 weeks instead of every 2; lebrikizumab every 4 weeks or even every 8 weeks in selected responders instead of every 2) with his patients.Closing thoughtsDr Cotter closes by highlighting the advantage of today’s toolkit: the flexibility to mix and match systemic and nonsteroidal topical therapies. This allows clinicians to tailor care, maintain long-term control, and address breakthrough disease with precision and safety.Key takeawaysAD must be framed as a systemic inflammatory disease to guide patient acceptance of systemic therapyDisease severity assessment should incorporate quality of life, high-impact areas, and patient-reported burden, not just EASI or BSATopicals remain essential for priming treatment, supporting systemics, and managing breakthrough diseaseFor partial responders, evaluate adherence to topicals before modifying systemic therapySwitching options include biologic-to-biologic transitions, class switching, or moving to small molecules; existing head-to-head data can help guide choicesJAK inhibitors can serve as short-term rescue agents before returning to biologics for long-term maintenanceWhen patients want to stop therapy, consider interval extension before discontinuation and counsel on expected durability of response by therapeutic classCombining systemics with modern, nonsteroidal topicals allows individualized, long-term disease control

In this episode of Topical Conversations, Matthew Zirwas, MD, and Raj Chovatiya, MD, discuss one of the most important, and sometimes underappreciated, aspects of atopic dermatitis (AD) management: rapid itch relief. Despite the progress made with targeted therapies, many dermatologists may still overlook how profoundly itch drives disease burden, adherence, and patient trust. Drs Zirwas and Chovatiya share practical approaches for evaluating itch severity, setting realistic expectations, and understanding how new-generation therapies are impacting the conversation around early symptom improvement.Why itch still warrants more attention in ADDespite the numerous treatment options for AD, Drs Zirwas and Chovatiya agree that itch remains an under-discussed symptom during dermatology visits. Dr Chovatiya points out that while dermatologists often assume they’re addressing itch adequately, in practice, they may not be asking the right questions about itch severity or fully exploring its impact on quality of life.Dr Zirwas adds that while the Numeric Rating Scale (NRS) for itch is useful in research, it’s less practical in routine clinical settings where patients are seen only every few months. Instead, he recommends a more straightforward, contextual approach: asking patients whether their itch is none, mild, moderate, or severe. He likens mild itch to a single mosquito bite, moderate to 20 mosquito bites or some poison ivy, and severe to widespread poison ivy or hundreds of bites. Framing the question this way, he explains, helps patients describe their experience more accurately and meaningfully.The broader impact: itch as a holistic problemDr Chovatiya emphasizes that itch is not a surface-level symptom, but rather drives a cascade of issues including sleep disturbance, fatigue, mood changes, anxiety, and depression. Persistent itch can also erode trust between patients and providers when relief isn’t achieved quickly enough, leading to frustration with otherwise effective treatment plans.Both dermatologists stress that understanding itch’s impact on quality of life is essential not only for patient empathy but also for maintaining long-term treatment adherence.A new era of therapies and a shift in expectationsThe landscape of AD therapy has evolved dramatically, introducing multiple biologic and small-molecule options that challenge old assumptions about speed and safety. Dr Chovatiya notes that dermatologists historically viewed biologics as “safe but slow,” but that perception no longer holds true. Today’s therapeutic arsenal includes IL-4/IL-13 inhibitors, IL-13 inhibitors, IL-31 inhibitors, and potentially soon, OX40 inhibitors, which are all capable of rapid and meaningful itch improvement.When discussing the pace of itch relief, both agree that while oral JAK inhibitors may deliver the fastest onset, biologics now demonstrate impressive early itch improvement as well. Dr Chovatiya points to real-world data showing that many patients experience noticeable relief early in their biologic therapy, not just lesion improvement.Tralokinumab and rapid itch reliefDr Zirwas highlights that among available biologics, tralokinumab provides balanced performance across efficacy, safety, and speed. He notes that data from the ECZTRA trials demonstrated separation from placebo within the first few doses, confirming that tralokinumab delivers meaningful early itch relief while maintaining long-term control and a favorable safety profile.While tralokinumab has sometimes been perceived as slow-acting, both dermatologists emphasize that this perception is not supported by clinical or real-world evidence. In practice, all approved biologics, including tralokinumab, can provide rapid and sustained itch improvement.Early itch relief is foundational to effective careDrs Zirwas and Chovatiya conclude that early itch relief is not just about comfort; it’s a cornerstone of patient satisfaction, adherence, and confidence in treatment. For patients with moderate to severe AD, agents like tralokinumab demonstrate that it’s possible to achieve rapid itch relief, visible skin improvement, and long-term disease control, all while maintaining a strong safety profile.Key takeawaysItch assessment deserves more attention: Despite being the hallmark symptom of AD, many dermatologists don’t ask enough about itch severity or its daily impact on quality of lifeQualitative scales may be more practical than numeric ones: Replacing the Numeric Rating Scale with simple categories paired with real-life comparisons helps patients describe their itch more accuratelyItch affects more than the skin: Persistent itch contributes to sleep loss, mood changes, and diminished confidence in treatment, highlighting the need for early and meaningful reliefModern therapies deliver faster relief than once believed: Biologics such as tralokinumab have shown clinically relevant itch improvement within the first few dosesBalance matters: Choosing treatments that address itch, skin clearance, safety, and adherence supports both short-term comfort and long-term control in patients with moderate-to-severe AD

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 childhoodDr. 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 proportionDrs 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, applicationThey 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 populationDrs 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 takeawaysAD can begin after 65: don’t dismiss late-onset disease in older adultsItch may far exceed visible inflammation: prioritize patient-reported pruritus and its impact on quality of lifeMatch regimen to reality: consider dexterity, vision, caregiver support, and polypharmacyBiologics can fit well for older adults: few interactions, interval dosing, strong itch and skin controlBe cautious with off-label antipruritics: renal/sedation risks are higher in this groupUse “theranostics “wisely: targeted biologic response can clarify the immunologic driver after serious causes are excluded

In this episode of Topical Conversations, Nicholas Brownstone, MD, sits down with Dawn Merritt, DO, to discuss the often-overlooked impact of atopic dermatitis (AD). While dermatologists may see a rash that appears mild, for many patients the disease affects far more than the skin, touching sleep, mental health, cognitive function, and overall quality of life across all age groups.Pediatric burdenDr Merritt emphasizes that pediatric patients and their families face a unique set of challenges. Children with AD often require multiple prescriptions per year, and caregivers may spend more than 10 hours weekly managing symptoms. This burden extends beyond the patient, commonly affecting parents’ time, energy, and mental health.The itch burden and mental healthPruritus is central to the disease burden in AD. Studies show patients with itch experience worse quality of life than those with chronic conditions like heart failure or stroke. Sleep disruption from itch can contribute to depression, anxiety, and even suicidal ideation. Dr Merritt notes that over 85% of patients with moderate-to-severe AD report at least itch or sleep disturbance as a symptom.Impact on school performanceChildren with AD may miss school due to rash, infection, or poor sleep. Even when present, they often struggle to concentrate (presenteeism), which can affect academic performance and self-confidence.Asking the right questionsBoth speakers stress the importance of asking beyond “How are you doing?” to uncover a patient’s full burden of AD. Specific questions about sleep, school, itch severity, and mental health allow patients and families to share concerns not visible on exam. Simple tools such as the Atopic Dermatitis Control Test or the PHQ-2 depression screen can help integrate formalized assessments into a busy clinic.Systemic therapies and emerging dataFor patients with significant quality-of-life impairment, Dr Brownstone recommends considering systemic therapy and referral to mental health support. Emerging data highlight that systemic biologics, such as dupilumab, may not only control skin symptoms but may also potentially improve growth outcomes and reduce ADHD medication needs in pediatric patients. A new therapeutic landscape for pediatric patientsSystemic options for AD have been expanding rapidly. Dupilumab is approved for patients as young as 6 months, while biologics such as lebrikizumab, nemolizumab, and tralokinumab are available for patients aged 12 and older. Compared to the limited options of the past, Dr Brownstone describes this as a “golden age” for pediatric AD management.Addressing comorbidities and empowering familiesDrs Brownstone and Merritt conclude their discussion by emphasizing that effective care includes addressing comorbidities such as sleep disturbance and depression. Dr Merritt also uses simple, relatable tools, like asking children to grade their AD with a letter grade, which helps track disease burden across visits. Both recommend connecting families to resources such as the National Eczema Association to provide education and empowerment.Key takeawaysAD can impact far more than the skin, affecting sleep, mental health, school performance, and family well-beingPruritus is a key driver of quality-of-life impairment and may be linked to higher rates of depression and suicidalityAsking specific, pointed questions or using simple screening tools can help clinicians uncover the true burden of disease for their patientsSystemic therapies like dupilumab are transforming pediatric AD care and may offer benefits beyond skin clearanceFor patients with even mild-appearing rashes but severe life impact, systemic agents or mental health referrals should be consideredProviding families with trusted resources, such as the National Eczema Association, can help foster education, empowerment, and adherence

In this episode of Topical Conversations, Graham Litchman, DO, MS, and Naiem Issa, MD, discuss the role of Janus kinase (JAK) inhibitors in atopic dermatitis (AD). These agents are increasingly valued for their efficacy and safety in clinical practice. A key advantage is the ability to individualize therapy through dose escalation, allowing JAK inhibitors to support a more personalized approach to managing this heterogeneous condition.Safety considerationsDr Litchman and Dr Issa review the safety profile of JAK inhibitors, noting that these medications are widely used and generally well tolerated. Large-scale studies of abrocitinib and upadacitinib, encompassing thousands of patients across multiple countries, support their safety and efficacy.Dr Issa emphasizes the importance of proactively addressing the boxed warning during patient discussions. Many patients will review the package insert and raise concerns, so he begins the conversation by explaining the history and context behind the warning. The boxed warning stems from the ORAL Surveillance study of tofacitinib vs TNF inhibitors in patients with rheumatoid arthritis aged 50 and older with cardiovascular comorbidities; many of these patients were on concomitant methotrexate and often corticosteroids. This population differs significantly from typical patients with AD.The “big 5” risks listed in the boxed warning (infection, major adverse cardiovascular events, thrombosis, sudden death, and malignancy) are framed as “reports” associated with JAK inhibitors, not as placebo-controlled findings. Dr Issa notes that clarifying this nuance helps patients understand the data in context and alleviates concerns. Dr Litchman adds that while these conversations can be complex, the majority of AD patients are not the same as the population studied in ORAL Surveillance, and most tolerate JAK inhibitors well in practice.Personalized treatment and dosing strategiesBoth experts highlight the role of JAK inhibitors in moving toward personalized medicine for AD, a heterogeneous and fluctuating disease. Treatment plans can be tailored based on individual patient needs, with the ability to adjust dosing when necessary.Data from studies such as the JADE and LEVEL UP trials support flexible dosing. For example, abrocitinib can be initiated at 100 mg daily, with evidence supporting escalation to 200 mg if additional efficacy is needed. Upadacitinib has a similar dose-response profile, with starting doses of 15 mg and higher efficacy seen with 30 mg. Importantly, long-term safety data have not shown an increased risk of adverse events of special interest when escalating to higher doses.In practice, Dr Issa often re-evaluates patients within 2 weeks, especially those with itch-dominant disease, and escalates dosing earlier if needed, supported by lab monitoring. Biological and mechanistic insightsBeyond clinical outcomes, Dr Litchman highlights emerging data on gene expression changes with JAK inhibitors. Studies suggest that these therapies, like biologics, may help normalize core gene sets associated with AD, particularly those related to itch pathways and skin barrier function. Observing both clinical improvements in itch and skin clearance, alongside genomic changes, reinforces confidence in the biological rationale for JAK inhibitor therapy.Key takeawaysSafety in context: Boxed warnings stem from rheumatoid arthritis data; most patients with AD tolerate JAK inhibitors wellFlexible dosing: Clinical trials support dose escalation (eg, increasing abrocitinib dosage from 100 mg to 200 mg or upadacitinib from 15 mg to 30 mg) without added long-term safety signalsBiologic rationale: Emerging gene expression data support the mechanistic role of JAK inhibitors in normalizing AD pathwaysFor a closer look at how dose escalation can influence outcomes in practice, explore a case report authored by Graham Litchman, DO, MS. It details a 25-year-old patient with longstanding, refractory atopic dermatitis who achieved complete clearance on abrocitinib following dose adjustment, with before-and-after photos documenting the clinical response.

In this episode of Topical Conversations, David Rosmarin, MD, joins Mary Gail Mercurio, MD, to discuss practical approaches to treating atopic dermatitis (AD) with dupilumab. The conversation covers treatment selection, patient counseling, insurance navigation, and evolving data on safety and adjunctive options. When to initiate systemic therapy Both note that the threshold for initiating systemic therapy, particularly dupilumab, has decreased as confidence in its safety and efficacy continues to grow. The broad range of FDA-approved indications, including approval down to 6 months of age, can help reassure patients who are hesitant to begin biologic therapy. The lack of lab monitoring requirements is also a significant benefit for both patients and clinicians. Patient counseling and injection hesitancy Patient hesitation around injectables can often be addressed through hands-on education and support from office staff. Dr Mercurio highlights the importance of in-office instruction in the use of the injection device. The growing body of safety data in pregnancy is also discussed, with both clinicians emphasizing the importance of forthcoming registry data and growing real-world evidence supporting dupilumab’s use during pregnancy. Follow-up and documentation Follow-up frequency varies based on patient preference and disease severity, often extending to 6 to 12 months once stable. Both clinicians document body surface area (BSA), symptom severity, and impact on quality of life, such as interference with sleep or daily functioning. Insurance considerations While dupilumab is typically approved without significant barriers, both clinicians note challenges when BSA is below 10%. Documenting involvement of high-impact areas like the face and hands and the broader impact on quality of life can aid in securing coverage. Assessing response and treatment duration The decision to continue or switch therapy is patient-specific. Some improvement may be expected within 3 months; if no response is observed by 3 to 4 months, a change in therapy may be warranted, especially in more severe cases. Mild cases may allow for a longer trial period before considering alternative options. Adjunctive therapies and managing residual disease For patients with residual symptoms despite dupilumab, both clinicians use topical therapies—steroids or nonsteroidals—based on body site. Phototherapy is viewed as a beneficial option but may be inaccessible due to cost or insurance limitations. Tapinarof and roflumilast are emerging nonsteroidal options, though access can be restricted by formulary status. Approach to acute flares In select cases, a short course of oral corticosteroids may be used to control acute flares while initiating dupilumab, helping to bridge the gap until biologic response is achieved. Looking ahead The discussion concludes with anticipation for new therapeutic options, including oral JAK inhibitors, oral STAT6 inhibitors, and other novel mechanisms. Dupilumab remains a foundational therapy in AD management, with new data, particularly regarding pregnancy safety and additional indications, expected to further shape clinical practice. Key takeaways Dupilumab is increasingly used earlier in the treatment course of AD due to a favorable safety profile and lack of lab monitoring requirements Patient education and support can ease concerns around injectable administration Documentation of quality-of-life impact and involvement of special sites can improve insurance approval likelihood, particularly for patients with <10% BSA involvement Adjunctive therapies, including topical agents and phototherapy, are frequently used to manage residual disease Treatment response is typically evaluated within the first 3 to 4 months to guide continuation or change in therapy

Understanding Systemic Treatment in Patients with Skin of Color In this episode of Topical Conversations, Cheri Frey, MD, and Amy McMichael, MD, discuss the use of systemic agents for treating atopic dermatitis and other skin conditions in patients with skin of color. They highlight biological differences, challenges in disease assessment, and practical strategies for improving outcomes and access to care. Biologic Differences and Disease Presentation Patients with skin of color may have lower ceramide levels, contributing to conditions like eczema. Dr Frey and Dr McMichael discuss how atopic dermatitis can present differently, with less visible erythema and more lichenification, hypopigmentation, or dyschromia. This variation can complicate severity assessments and insurance approvals. Health Literacy and Access to Care Both physicians emphasize the importance of educating patients and their families about skin care and the safety of systemic therapies. Dr McMichael points out that socioeconomic factors and low health literacy can limit access to effective treatments. She underscores the need for outreach to primary care providers to ensure timely referrals to dermatologists. Tools and Severity Assessment Standard scoring tools that rely on visible erythema may underrepresent disease severity in skin of color. Dr McMichael advises focusing on symptoms like itching and lichenification to accurately capture disease burden and support treatment decisions. Early Intervention and Improved Outcomes Dr Frey advocates for earlier use of systemic treatments to break the itch-scratch cycle and prevent complications like dyschromia and nodular scars. Dr McMichael highlights the role of newer systemic agents targeting cytokine pathways, such as IL-4 and IL-13, which have transformed atopic dermatitis management. A Personal Success Story Dr Frey shares a memorable patient case: a young girl who felt too embarrassed by her skin to join cheerleading. After starting a systemic medication, she not only joined the team but excelled, demonstrating how timely intervention can restore confidence and quality of life. Key TakeawaysAtopic dermatitis often presents differently in patients with skin of color, requiring tailored assessment beyond visible erythema.Health literacy, socioeconomic factors, and provider education are key to improving access to systemic therapies.Systemic agents can break the itch-scratch cycle early, reducing complications and improving quality of life.Newer biologics targeting IL-4 and IL-13 offer safe and effective options for severe cases.Personal stories highlight the transformative impact of early, appropriate therapy.

From Environmental Triggers to Emotional Toll In this episode of Topical Conversations, Michelle Tarbox, MD, and Peter Lio, MD, take a comprehensive look at the evolving landscape of atopic dermatitis (AD), a condition that continues to challenge patients, families, and clinicians alike. They explore the multifaceted burden of AD, from environmental triggers and treatment fatigue to the far-reaching impact on patients and their families.Cold Weather, Wildfire Smoke, and the Skin Barrier Dr Lio notes that winter often triggers AD flares due to dryness and disrupted skin barrier function. He highlights emerging research identifying isocyanates—components of wildfire smoke—as potential microbiome disruptors that may directly worsen AD. Dr Tarbox references data linking increased AD clinic visits and hospitalizations to wildfire exposure, reinforcing the importance of climate-related awareness in dermatology. When Topicals Aren’t Enough While mild AD can often be managed with topical therapies and gentle skin care, more severe cases require a different approach. They discuss treatment challenges such as poor adherence in children, fear of stinging medications, and the physical and emotional strain on families. Dr Lio breaks down why topicals sometimes fail and advocates for timely escalation to systemic therapy when appropriate. The Family Burden and the Path Forward The impact of AD extends beyond the skin. Dr Tarbox describes how the condition can dominate daily routines, strain marriages, and even disrupt childhood growth due to chronic inflammation and sleep loss. Both physicians emphasize the importance of moving from the vicious cycle of uncontrolled disease to a virtuous cycle of healing and how newer biologic and oral treatments are making this more achievable than ever before. Biologics and the “Renaissance” in AD Treatment With multiple systemic therapies now available, including biologics for children as young as 6 months, patients and providers are entering a long-awaited “renaissance” in AD care. Dr Tarbox draws comparisons to the revolution seen in psoriasis treatment, noting how gratifying it is to now have effective tools for patients with eczema. Dr Lio adds that some newer therapies may even allow for reduced dosing over time, a hopeful sign for long-term disease control. Shared Decision-Making and Long-Term Trust Treating AD means building relationships. Both physicians advocate for shared decision-making and patience when introducing systemic options, especially in pediatric cases. Dr Lio shares a helpful tool: the Atopic Dermatitis Control Tool (ADCT), which helps patients recognize how deeply AD affects their lives. They close by emphasizing the value of listening, following up, and guiding families toward relief without pressure, but with compassion and clear options. Key Takeaways Environmental triggers like cold weather and wildfire smoke can worsen AD and damage the skin barrierAD affects the entire family and can impact child development, sleep, and quality of lifeTopical therapies are not always enough; systemic options, including biologics, are now available for some casesTimely treatment can prevent disease “hardening” and improve long-term outcomesShared decision-making and regular follow-up help patients feel empowered and supported

Atopic Dermatitis: A Systemic Disease In this episode of Topical Conversations, Michael Lewitt, MD, and James Song, MD, explore the systemic nature of atopic dermatitis (AD) and its far-reaching effects beyond the skin. Drawing comparisons to psoriasis, they discuss how inflammation in AD is not confined to lesional areas, but extends to non-lesional skin, the bloodstream, and other organ systems—making the need for early recognition and intervention increasingly urgent. Comorbidities: Atopic and Beyond Drs Lewitt and Song break down the diverse comorbidities associated with AD. Atopic conditions such as asthma, allergic rhinitis, eosinophilic esophagitis, and allergic conjunctivitis are common, but so are non-atopic burdens like sleep disturbance, reduced school and work productivity, and complications from systemic steroid use. They highlight the importance of recognizing both types of comorbidities to guide management strategies. Prioritizing Conversations in a Short Visit Given the time constraints of typical dermatology visits, both physicians emphasize using a "high-yield" mental checklist to screen for potential comorbidities. Asking simple questions about breathing, swallowing, nasal symptoms, and eye dryness can help uncover issues early. Dr Song underscores that while dermatologists cannot manage every comorbidity, timely recognition and referral are key. The Role of Early Intervention Early treatment of AD may do more than control current symptoms—it could potentially prevent the development of future comorbidities. They discuss how therapies targeting key cytokines like IL-4 and IL-13 might reduce barrier dysfunction and immune activation, ultimately altering the long-term trajectory of the disease. For pediatric patients especially, intervening early could disrupt the "atopic march" toward additional allergic diseases. Collaborating Across Specialties Both doctors advocate for strong collaboration with allergists, pulmonologists, gastroenterologists, and mental health providers when managing complex cases. Dr Lewitt likens it to having multiple cooks in the kitchen making the same dish—working together toward shared patient goals. Dermatologists, they agree, are often in the ideal position to recognize systemic signs first and initiate appropriate care pathways. Key TakeawaysAtopic dermatitis is a systemic inflammatory disease that extends beyond the skin. Common comorbidities include both atopic (asthma, allergic rhinitis) and non-atopic (sleep disturbances, productivity loss) conditions. Early screening for comorbidities during dermatology visits can improve patient outcomes. Early intervention with targeted systemic therapies may help prevent the progression of the atopic march. Collaboration with other specialists is critical for comprehensive patient care.

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 Systemic therapy is often delayed in AD, despite evidence that earlier intervention can improve outcomes and prevent progression Patient education is crucial; dermatologists should aim to help them understand that AD is driven by internal inflammation that topicals may not address More dermatologists need to embrace systemic therapy, as current prescribing rates remain low despite the strong safety profiles of modern biologics Lebrikizumab offers a unique approach to IL-13 inhibition, showing significant itch reduction and sustained efficacy even after treatment discontinuation Patient fears about systemic therapy are often based on outdated perceptions, making it essential for dermatologists to address misconceptions head-on

In this episode of Topical Conversations, Dr. Michael Cameron and Dr. Graham Litchman explore the pathophysiology of type 2 inflammation in dermatologic diseases and discuss how evolving treatment options are reshaping clinical practice. From atopic dermatitis (AD) and prurigo nodularis (PN) to chronic spontaneous urticaria (CSU), they break down the mechanisms of disease, targeted therapies, and emerging treatment strategies that are changing the way dermatologists approach inflammatory skin conditions. Understanding type 2 inflammation across dermatologic diseases Since the approval of dupilumab in 2017, research into type 2 inflammation has expanded dramatically. Dr. Litchman highlights how this shared inflammatory pathway connects conditions such as asthma, allergic rhinitis, AD, PN, and CSU, allowing dermatologists to educate patients on the systemic nature of their disease. Dr. Cameron emphasizes the complex immune dysregulation in type 2 diseases, particularly the cross-talk between inflammatory cells. He explains that IL-4 and IL-13, key drivers of AD and PN, are present not only on inflammatory cells but also on sensory nerves, contributing to chronic itch. Targeted therapies like dupilumab, tralokinumab, lebrikizumab, and nemolizumab work by interrupting these signaling pathways, leading to symptom relief. Emerging therapies and novel mechanisms of action The discussion shifts to next-generation treatments that go beyond blocking cytokine communication to directly targeting inflammatory cells. Dr. Litchman shares excitement about the potential of Bruton’s tyrosine kinase (BTK) inhibitors that prevent mast cell activation and degranulation; JAK1 inhibitors that have the potential to expand options for systemic inflammatory control; monoclonal antibodies that look to directly inhibit IL-5, IL-13, and eosinophils, offering new avenues for treatment; and OX40 ligand inhibitors, that work by eliminating pathogenic T cells rather than just blocking their signals. Dr. Cameron highlights key priorities in drug development, including longer dosing intervals (every 3 months), higher efficacy (bispecific and trispecific antibodies), and more oral treatment options. The role of dermatologists in managing CSU and PN CSU is often referred out, but both doctors agree that dermatologists should reclaim these patients. Dr. Cameron points out that many patients with CSU patients are also atopic, reinforcing that dermatologists are well-equipped to manage their care. With BTK inhibitors and anti-c-Kit therapies emerging, now is the time to bring CSU management back into dermatology practices. For PN, the approval of dupilumab and nemolizumab has been a breakthrough. Previously neglected due to a lack of therapeutic options, patients with PN now have access to effective, targeted treatments. Dr. Cameron emphasizes that many patients with PN also have coexisting atopic conditions, making these therapies beneficial beyond PN alone. Key takeaways: Type 2 inflammation plays a central role in several dermatologic conditions, including atopic dermatitis, prurigo nodularis, and chronic spontaneous urticaria Emerging treatments, including BTK inhibitors, JAK1 inhibitors, and OX40 ligand inhibitors, offer new approaches by targeting inflammatory cells directly rather than just blocking cytokines Prurigo nodularis treatment has advanced, with new options providing effective options for a previously difficult-to-manage condition It is crucial that dermatologists remain informed about new mechanisms of action to optimize individualized patient care as treatment options expand

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 Diagnosing AD in skin of color requires looking beyond redness, focusing on texture, itching, and pigmentary changes Systemic therapy should be considered when AD significantly impacts daily life, especially when topical treatments are insufficient Hyperpigmentation often improves over time, but hypopigmentation can be permanent, emphasizing the importance of early, aggressive treatment Newer biologics, like lebrikizumab, show promising results in addressing AD Cultural considerations and patient adherence play a major role in treatment success, requiring a simplified, consistent, and collaborative approach

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: Skin barrier dysfunction: The barrier is compromised, allowing irritants and allergens to penetrate Overactive immune response: The immune system overreacts to normal stimuli, driving inflammation 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: Plant the seed early: Introduce the concept of systemic treatment as a possibility, allowing families time to consider the option Address misconceptions: Explain the significance of treating AD thoroughly and the potential ramifications of delaying care Build trust: Begin with topical treatments where appropriate to establish a connection with the family, then revisit systemic options if necessary 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 Early intervention is crucial: Treating AD early, particularly in young patients with a family history of atopy, is key to mitigating the atopic march. Skin barrier care matters: Educating parents about the importance of maintaining the skin barrier with appropriate products is foundational. Consider systemic therapies: Dupilumab may reduce the burden of AD and potentially prevent or mitigate other atopic conditions Communication is key: Dermatologists must navigate conversations with parents to address misconceptions, build trust, and emphasize the importance of managing AD thoroughly

In this year-end episode of Topical Conversations, Dr Peter Lio provides an insightful overview of the evolving landscape of atopic dermatitis (AD) treatments and trends to watch in 2025. With advancements in AD care beginning to close the gap with psoriasis, Dr Lio shares practical recommendations to help dermatologists prioritize areas for education and optimize patient care. Advancements in atopic dermatitis treatments: catching up with psoriasis Dr Lio notes that AD care is undergoing a significant evolution, with a wave of new treatment options raising the bar for patient outcomes. He explains how the expanding therapeutic toolbox challenges dermatologists to reevaluate whether current treatments are meeting patients' needs—and whether there’s room to do better. The rise of nonsteroidal topicals For decades, corticosteroids were the cornerstone of topical AD therapy. However, the introduction of nonsteroidal options has shifted the paradigm: Tacrolimus and pimecrolimus (approved in 2000–2001): These calcineurin inhibitors offered the first robust nonsteroidal options but are not suitable for everyone due to boxed warnings, stinging, and burning Crisaborole (2016): As the first PDE4 inhibitor approved for dermatologic use, it paved the way for this class but faced challenges with tolerability Topical ruxolitinib (2021): A JAK inhibitor, it is one of the most potent nonsteroidal options. While effective, its boxed warning requires cautious use, limiting application to less than 20% of body surface area and avoiding continuous treatment. Topical roflumilast (2024): Previously approved for psoriasis and expanding into AD in 2024, this once-daily PDE4 inhibitor offers ease of use and no boxed warning, making it ideal for proactive, long-term management Tapinarof (2024): Recently approved for AD, this aryl hydrocarbon receptor agonist shows promise for its potential remittive effect, allowing extended results even after treatment cessation. However, dermatologists must work toward defining remission and its distinction from cure. Biologics and systemic advances Dr Lio also reviews biologic therapies that are revolutionizing moderate-to-severe AD treatment, offering targeted solutions: Lebrikizumab (2024): Targeting IL-13, this biologic binds differently than existing IL-13 inhibitors, demonstrating high affinity and potentially enhancing patient outcomes Nemolizumab (2024): Approved for prurigo nodularis and now AD, it works via a novel pathway, further diversifying systemic options for dermatologists What 2025 holds for atopic dermatitis Dr Lio remarks that with a robust and diverse treatment toolbox, dermatologists are better equipped than ever to manage AD. This new era calls for: Shared decision-making: Engaging patients in treatment planning to align with their goals and preferences Stewardship of medications: Balancing efficacy, safety, cost, and access to deliver patient-centered care Innovative approaches: Exploring new treatment strategies, including acute care, long-term maintenance, and proactive management Dr Lio emphasizes that the wealth of new options allows dermatologists to offer renewed hope to patients who previously felt they had exhausted their choices. By leveraging this expanded toolbox, dermatologists can provide more effective, tailored care in 2025 and beyond, potentially helping patients achieve better outcomes and sustained symptom control.

In this episode of Topical Conversations, Dr James Del Rosso and Dr Alexandra Golant explore the nuanced use of dupilumab in treating moderate atopic dermatitis (AD), particularly in long-term management. Their discussion provides valuable perspectives on patient education, managing treatment expectations, and the unique benefits of dupilumab for both pediatric and adult patients with AD. A paradigm shift in AD management Dr Golant highlights the impactful effect of dupilumab in treating AD, describing it as a major milestone in dermatology. Since its approval, dupilumab has significantly enhanced disease control for patients, with many individuals remaining clear for years. Initially approved for adults, dupilumab has extended its reach, now approved for use in children as young as 6 months. Addressing parental concerns in pediatric patients When discussing the treatment of young children, Dr Del Rosso posits a scenario where a one-year-old patient’s parents have attempted topical steroids or nonsteroidal therapies without success. Dr Golant emphasizes the importance of educating parents about the systemic nature of AD to create a more receptive environment for systemic therapy discussions. She refers to this as “disease state re-education,” which involves explaining AD's systemic inflammatory nature and discussing how dupilumab works to address inflammation on multiple fronts. Explaining Systemic Therapy to Parents For parents open to considering systemic therapy, Dr Golant often addresses the common concern of treatment duration, especially in younger patients. With dupilumab, the goal is not only to manage AD symptoms but to potentially influence the “atopic march” or the progression of allergic diseases over time. However, she notes that long-term outcomes are still being studied, particularly in infants and young children. Overcoming injection concerns Dr Del Rosso acknowledges that the injectable nature of dupilumab may initially deter some parents. However, he points out that the biweekly dosing schedule makes treatment less burdensome than the daily application of topical therapies. Dr Golant finds that once parents see the positive results, their hesitancy often diminishes, as they realize the level of control that systemic therapy can offer. The role of topicals in conjunction with systemic therapy While dupilumab allows many patients to reduce their reliance on topicals, Dr Golant describes them as “touch-up paint” for spot treatments that may still be necessary. In clinical practice, these topicals—such as corticosteroids and calcineurin inhibitors—are often used alongside dupilumab to help manage flare-ups or persistent areas of inflammation. Recognizing moderate AD as worthy of systemic intervention Dr Golant emphasizes that moderate AD can still have a high impact on patients' quality of life, even when the body surface area (BSA) affected is relatively low. For instance, severe eczema on the hands or face can cause significant discomfort and disrupt sleep, impacting daily life considerably. Dr Golant believes that patients with moderate AD often benefit substantially from systemic treatments like dupilumab and stresses the importance of assessing AD's impact on quality of life, rather than focusing solely on BSA affected. Dupilumab’s benefit for comorbid conditions One significant advantage of dupilumab is its efficacy across a range of atopic conditions. For patients with AD who also have nasal polyps, asthma, or eosinophilic esophagitis, dupilumab’s effects may extend to these conditions as well. Dr Golant recommends dermatologists take a thorough history to identify any additional comorbidities that dupilumab might positively impact, making it a versatile choice for many patients. Monitoring Progress and Setting Treatment Goals For tracking the progress of AD treatment in patients, Dr Del Rosso recommends the Atopic Dermatitis Control Tool as a practical and efficient way to assess symptom control. Dr Golant agrees, and also emphasized the importance of shared decision-making with patients and aligning on treatment goals and quality-of-life improvements. In follow-up visits, she discusses practical impacts on quality of life, such as improvements in sleep or reduced limitations in daily activities. Responding to questions on long-term use When asked how long patients or their children should remain on dupilumab, Dr Del Rosso explains that his approach has evolved. Rather than recommending indefinite use, he now focuses on achieving optimal disease control and leaving the decision to continue treatment flexible. This open-ended approach reassures patients and builds trust, as they can feel confident in stopping treatment if they are uncomfortable at any point. Key takeaways for dermatologists The conversation between Dr Golant and Dr Del Rosso underscores the importance of effective communication with patients and families about systemic therapy options like dupilumab. They emphasize the necessity of educating patients on the systemic nature of AD, addressing concerns around injectables, and recognizing that even moderate AD can warrant systemic treatment.

In this episode of Topical Conversations, James Q. Del Rosso, DO, gives an overview of the emerging role of the OX40/OX40 ligand (OX40/OX40L) pathway in the treatment of atopic dermatitis (AD). As research continues to advance, this pathway has gained attention as a promising therapeutic target that could offer longer-lasting relief for patients with AD by addressing the root causes of inflammation. What is the OX40/OX40 ligand pathway? The OX40/OX40 ligand pathway is a key regulatory mechanism in the immune system, playing a crucial role in the communication between immune cells. Specifically, this pathway is believed to govern type 2 inflammation, which is central to the development of AD, at its source. OX40, found on activated T lymphocytes, and OX40 ligand, present on antigen-presenting cells, act as costimulatory molecules that enhance the activation and proliferation of T cells, particularly Th2 lymphocytes. This T cell activation leads to the chronic inflammation characteristic of AD. Dr Del Rosso explains that when this pathway is activated, it not only contributes to the immediate inflammatory response but also influences immune memory. This means that the pathway helps sustain the immune system's ability to reactivate inflammation during flare-ups and may contribute to the persistence and recurrence of AD over time. Targeting OX40/OX40 ligand in AD treatment Given the critical role of the OX40/OX40L pathway in driving inflammation and disease recurrence, blocking this pathway has become a focus for new AD therapies. Two agents are currently under investigation—amlitemab, which binds to OX40 ligand, and rocatinlimab, which targets OX40. Both therapies aim to inhibit the expansion of T cells that lead to the acute flares seen in AD and block the memory T cells responsible for long-term recurrence. By interfering with this pathway, these treatments have the potential to work on 2 levels: reducing the severity of current flares and preventing future ones. This dual action could represent a significant advancement in AD management, moving beyond symptom control to more durable, long-term disease modification. A paradigm shift in AD treatment As Dr Del Rosso emphasizes, paying attention to the OX40/OX40 ligand pathway is critical as it represents a novel approach to treating AD at its source. By addressing the underlying mechanisms that drive both acute and chronic inflammation, these therapies could transform how dermatologists manage AD, offering patients not only symptomatic relief but also the possibility of long-term remission. For more on this topic, tune in to the Derms and Conditions episode, The OX40/OX40L Pathway: Expanding Our Understanding of Atopic Dermatitis

In this episode of Topical Conversations, Heather Gates, PA-C, and Marc Serota, MD, explore the challenges and treatment strategies for patients with moderate atopic dermatitis (AD). They emphasize the importance of assessing patients accurately and highlight the evolving role of systemic therapies. Understanding moderate atopic dermatitis: assessing the patient Patients with moderate AD often present with fluctuating symptoms. They may appear well on the day of their visit but experience significant discomfort during flare-ups. According to Dr Serota, dermatologists must go beyond the snapshot of what they see in the office and dig deeper into the patient’s daily experience with the disease. Important factors to assess include: Body surface area (BSA): Evaluate the extent of the skin involvement over time, not just at the visit. Itch intensity: Gauge how severe the itch typically is, on a scale from 1 to 10. Impact on daily life: Ask about the emotional and social effects, especially in pediatric patients who may experience itch during activities like sports or in school settings. These considerations often reveal that even if a patient seems to have mild symptoms in the office, their overall burden of disease is much more significant. Transitioning from topicals to systemic therapies Deciding when to transition from topical treatments to systemic options is crucial in AD management. As Heather Gates and Dr Serota explain, the availability of newer, safer systemic therapies has shifted the conversation. Both Gates and Serota agree that every patient with AD should have a topical treatment available, particularly nonsteroidal options. This remains a staple of treatment regardless of whether the patient is on systemic therapy. Historically, systemic treatments like methotrexate were avoided early in treatment plans, especially in pediatric cases. However, with the introduction of safer alternatives such as dupilumab, Dr Serota now initiates the conversation about systemic options early, even during the first visit for patients with moderate AD, noting that these patients deserve to be informed of all treatment options, and the decision on whether to start systemic therapy can be made collaboratively. Choosing a systemic therapy Selecting the right systemic therapy for moderate to severe AD depends on several factors, including the patient’s age, comorbid conditions, and the severity of their symptoms. Newer systemic therapies have provided safer alternatives to traditional treatments like methotrexate and cyclosporine, which were often associated with significant side effects. Dr Serota highlights the utility of dupilumab for patients with comorbid conditions, noting that with its indications for associated atopic conditions, it can address skin symptoms as well as target related conditions such as asthma, making it a holistic treatment option for patients with multiple atopic diseases. Communicating systemic treatment options to patients and parents When discussing the possibility of systemic treatments, setting realistic expectations is critical. Gates and Serota emphasize the importance of framing the conversation in a way that is clear, reassuring, and rooted in long-term management. Gates advises underselling the benefits and overdelivering. She stresses to parents that AD is a chronic disease, and the child will likely need long-term therapy. This helps prevent disappointment and encourages adherence. Dr Serota uses simple analogies to help explain systemic treatments. For example, he compares dupilumab to a radio signal blocker that specifically targets allergic cells, avoiding broad immunosuppression. He also compares the injection schedule to that of diabetes treatments, explaining that the infrequent administration (every two weeks or once a month) is manageable compared to daily insulin injections. Systemic therapy for moderate AD: a shift in treatment paradigms With advances in systemic therapies, the approach to treating moderate atopic dermatitis has shifted dramatically. Dermatologists are now empowered to initiate conversations about systemic treatments earlier in the disease course, offering patients the chance to live with less itch, better sleep, and improved quality of life. Even if patients choose not to proceed with systemic therapy, ensuring that they are aware of the benefits, risks, and availability of these treatments is essential for shared decision-making and better long-term outcomes.

In this episode of Topical Conversations, Kristine Kucera, PA-C, and Aaron Farberg, MD, discuss the challenges of managing moderate atopic dermatitis (AD). This segment offers insights into how clinicians define moderate AD, set treatment goals, and decide when to move beyond topical therapies to systemic treatments. Defining moderate atopic dermatitis Dr Farberg highlights that defining the moderate AD patient can vary depending on the context. In clinical trials or insurance approvals, moderate to severe AD is often based on scoring systems like the EASI score. However, in practice, the definition relies on a more personal approach—talking to the patient and assessing the impact of the disease on their daily life. For clinicians, body surface area (BSA) is often used to classify AD severity, but Dr Farberg emphasizes that the location of eczema can sometimes be more telling than the extent of coverage. For example, AD affecting sensitive areas like the scalp or groin may have a significant impact on quality of life even if it doesn’t affect a large area of skin. He suggests that the key is understanding how AD affects the patient, which helps determine whether a patient should remain on topical treatments or transition to more systemic options. Treatment goals for moderate atopic dermatitis According to Kristine Kucera, setting clear treatment goals is critical, starting with patient education. Patients need to understand their condition and the rationale behind the treatment approach. Kucera advocates for shared decision-making to establish patient-specific treatment goals, ensuring both the clinician and patient are aligned on expectations. Patients may not always realize what is achievable with appropriate treatment. Kucera emphasizes that even if patients feel they are "doing okay," clinicians should probe deeper to assess if lingering flares or other symptoms remain. Better control of symptoms can significantly improve a patient’s quality of life, and patients often don’t realize how much improvement is possible. Dr Farberg highlights the importance of aiming for near-complete clearance. Studies in related conditions like psoriasis have shown that getting a patient from 75% to 90% or more clearance can lead to meaningful improvements in quality of life. This goal should be communicated clearly to patients, ensuring they understand that optimal control can be within reach. Skin care and basic advice for moderate AD patients Both Dr Farberg and Kucera stress the importance of providing patients with advice on basic skin care routines. Clinicians should not overlook recommending gentle skin care practices, including using gentle cleansers, moisturizing frequently, trimming nails to prevent scratching, and using a humidifier. These foundational steps can complement medical treatments, helping patients maintain better control over their symptoms. Transitioning to systemic treatments: when and why The decision to move from topical treatments to systemic therapies is pivotal in managing moderate AD. According to Dr Farberg, the conversation about systemic treatments should happen early, even during the first visit. Discussing options like JAK inhibitors and cytokine inhibitors, such as dupilumab (Dupixent), helps patients understand their choices upfront, reducing the likelihood of patients questioning why certain treatments weren’t offered sooner. For moderate AD, Dr Farberg emphasizes the importance of treating the disease as systemic from the outset. While topical therapies are useful, many patients require a systemic approach to achieve meaningful control. Dupilumab: a go-to treatment option When it comes to systemic therapies, dupilumab has emerged as a strong option in the treatment of moderate atopic dermatitis. Dr Farberg explains that dupilumab is well-tolerated, with a safety profile supported by years of use across various conditions. Patients are increasingly open to the idea of injections, particularly with the rising familiarity of injectables like GLP-1 inhibitors for other health conditions. Dupilumab’s every-two-week injection schedule, with the possibility of extending to once a month in certain cases, appeals to many patients who prefer fewer interventions compared to daily oral medications. Personalized care for moderate AD patients Both Kucera and Dr Farberg highlight the importance of personalized treatment approaches for moderate AD. Every patient is different, and clinicians need to be flexible in tailoring treatments to individual needs. With an array of available options, from topicals to systemics like dupilumab and JAK inhibitors, the goal is to find the right combination that maximizes each patient’s comfort and quality of life. By engaging in open discussions with patients, setting realistic treatment goals, and considering early transitions to systemic therapies, clinicians can help patients achieve better disease control and improve their daily lives.