Reframing AD as Systemic, Type 2 Inflammation
Neita and Miranti open by resetting the mental model for atopic dermatitis. As Neita puts it, this is not just an itchy rash — it is a systemic inflammatory condition. He points to the atopic triad, reminding listeners that these patients carry higher risk for environmental and food allergies as well as asthma, so the disease reaches well beyond the skin.
Miranti connects that framing to therapy selection. The more the field learns about type 2 inflammation, she notes, the more it explains the barrier dysfunction, the comorbidities, and why our therapeutic options should target that type 2 pathway rather than just quiet the surface. Both hosts credit fellow PA Douglas DiRuggiero, whose lectures at the Elevate-Derm RAPIDS conference in Puerto Rico pushed them to think like 'immunodermatologists,’ enough to explain to patients why newer therapies work differently from what they've tried before.
Skincare Is the Foundation — Including the Don'ts
Before any drug, both hosts anchor treatment in skincare. Miranti recommends fragrance-free, sensitive-skin cleansers and emollient moisturizers, and says she isn't married to a single brand—she’ll sample one product or steer highly allergic, preservative-sensitive patients toward the gentlest options. Her practical tip: give patients brand names they recognize or coupons where you circle the exact product, because the grocery-store aisle overwhelms them and they'll pick the pretty packaging over the right formulation.
Bathing counseling matters just as much. Miranti advises short, lukewarm (not hot) showers, patting dry, and applying emollients immediately. Neita adds the don'ts: no scrubbing, no loofahs stripping every scale, and caution with medicated salicylic acid or benzoyl peroxide products that can harm a compromised atopic barrier. Handouts help reinforce it all.
Topical Steroids and the Older Non-Steroidals
Miranti, who describes herself as old-school after 20-plus years in practice, still uses topical corticosteroids and TCIs — but positions them as step-throughs and rescue therapy, not everyday treatment. She likes the asthma-rescue analogy for patients and family members who already understand the concept. Neita agrees they retain value, and notes insurers often require these step edits before newer agents.
On PDE4 inhibitors, the hosts contrast the older crisaborole with newer roflumilast. Neita finds crisaborole has fallen out of favor given stinging, irritation, and modest efficacy, though its indication down to three months is a real asset - just counsel caregivers about burning and avoid broken skin. Roflumilast, approved down to age six for AD, is a once-daily option Miranti loves for AD/seb derm crossover patients. She stresses specifying the formulation for the MA — the roflumilast 0.15% cream for atopic dermatitis — and highlights its low incidence of stinging on sensitive areas like eyelids, face, folds, and genitalia, plus data supporting improvement in post-inflammatory dyschromia in skin of color.
The Newest First-in-Class and JAK Options
Miranti is 'highly impressed' with topical tapinarof cream, a first-in-class aryl hydrocarbon receptor agonist approved for both atopic dermatitis and psoriasis, with an AD indication down to age two. She praises the trial design: roughly 80% of enrolled patients were children with deliberate recruitment of younger ages, more than half were skin of color to study dyschromia, and the company enrolled moderate-to-severe patients — potential biologic candidates — and got more than half to clear or almost clear with once-daily use. Neita reports reasonable coverage and strong rebate programs.
The hosts also cover topical ruxolitinib ('rux cream'), approved for AD and vitiligo, dosed twice daily, limited to 20% body surface area, for patients 12 and older. Its advantages include use in sensitive areas where you'd avoid steroids and rapid itch relief — some patients had statistically significant improvement in just 15 minutes. The catch is the JAK inhibitor boxed warning. Miranti explains its origin: an oral JAK inhibitor studied in patients with rheumatoid arthritis 50 and older with cardiovascular risk factors, where an increased rate of major adverse cardiovascular events (not all-cause mortality) was seen. She notes the class warning was applied even though the oral ruxolitinib released years earlier doesn't carry it, and she hopes the FDA reconsiders. Both hosts agree that painting an accurate, honest risk picture keeps parents receptive — much like the earlier TCI boxed warning experience.