From 'Best We Can Do' to Precision
Buchi Neita, PA-C, opens by reminding listeners how far the field has come. Before 2017, systemic options for atopic dermatitis were essentially steroids or off-label immunosuppressants like cyclosporine and methotrexate—modestly efficacious and, as she and PA Eileen Cheever agree, carrying real safety concerns whether used short-term or long-term. Today the landscape includes four approved biologics and two oral JAK inhibitors in the US.
Cheever describes the shift as changing 'everything.' The conversation used to center on what clinicians couldn't do; now it centers on disease control, itch relief, sleep, quality of life, and long-term management. She no longer frames moderate-to-severe patients as people who 'just have to live with it.' Neita adds that she tells patients directly that many of these medications have been game changers, and that she feels more hopeful treating this population.
Matching the Right Patient to the Right Therapy
When choosing among the four biologics, Cheever says the privilege now is moving beyond 'does this patient need a biologic?' to 'which biologic fits this individual?' She weighs whether itch is the dominant, most burdensome complaint, how sleep and quality of life are affected, and comorbidities within the type 2 inflammatory diathesis—asthma, rhinosinusitis, GI issues. She also considers age, comfort with injections versus a preference for oral therapy, and what 'freedom' means to each patient.
For a patient with severe AD and uncontrolled asthma, she reaches for a therapy carrying both indications. When itch drives the suffering and patients are in agony, she thinks about speed. Neita notes more flexibility now, citing data on lebrikizumab potentially being effective at every-week dosing as an example of broadening what clinicians can offer.
When to Switch—and Investigating Why
Cheever sets expectations early, framing a partial response or tolerability issue as a 'pit stop' rather than a failure. Before switching, she investigates: Is the patient a partial responder? Could an adjunctive topical help? Is there an adherence issue? Or is a concomitant diagnosis contributing? Neita reinforces this, warning against reflexively dismissing the drug and jumping to the next thing the way clinicians got used to doing in psoriasis—AD still has fewer options.
Timing depends on severity and trajectory. If Cheever sees meaningful progress, she is willing to be patient and even 'cheerlead' the patient to stay the course. If improvement plateaus or symptoms remain problematic day to day, she considers a change—sometimes within the biologic class, sometimes to something entirely different when faster control is needed. JAK inhibitors, she says, come to mind. She is also a self-described steward of her toolbox, lowering her threshold for aggressive control in severely affected patients (missing work, caregiving demands) while being more conservative with patients who simply want improvement.
Where JAK Inhibitors Fit First
For Cheever, route of administration is the number one driver toward a JAK—many patients want systemic control by mouth. She has also been repeatedly impressed by the speed of JAK inhibitors, including outside AD, describing patients who walk in unable to sleep, scratching until they bleed, cycling through antibiotics, and asking for work notes. That rapid itch reduction, she says, is setting a bar a little faster than what's historically been expected from biologics. Lifestyle matters too—patients who travel may prefer a medication without special refrigeration.
Neita highlights that JAKs let clinicians avoid the old default of prednisone or intramuscular steroids for severe flares, sparing patients steroid-related risks like hypertension and blood sugar changes, especially those with metabolic issues. Cheever notes the recent AAD guidelines reflect this in a green/yellow/red light format—prednisone now sits in the red, while JAK inhibitors carry a strong recommendation, including for appropriate pediatric patients by age and FDA approval.
Cheever calls out additional JAK candidates: patients with ambiguous or chronic ocular surface disease, and a 'booming' population in her practice—adolescent AD patients, often males, who were controlled on biologics when parents did the injections but now resist the shots. These generally healthy teens tend to be among her safest, most satisfying JAK patients. Neita adds that JAKs can be valuable for ambiguous presentations with overlapping features, and both note the cross-talk between dermatology and rheumatology, where shared FDA-approved JAKs enable collaborative care of comorbid conditions.
The Boxed Warning Conversation and Common Misconceptions
Neita frames the boxed warning as 'the elephant in the room,' though Cheever notes it's getting smaller. Cheever's key point: confidence comes from truly understanding the pathophysiology, mechanism, data, and safety of JAKs. Using Neita's artist analogy, she says clinicians perfect the craft through mentors and education, and that a clinician's confidence naturally comes through when they educate patients. Her framing today is balanced—rigorous trials, solid monitoring protocols, individualized risk—putting the warning in context rather than reciting only the wording, without minimizing risk.
She addresses three misconceptions among colleagues. She does prescribe JAKs to females on birth control, weighing the thromboembolic risks of both against each other with informed consent. She prescribes to smokers with documented motivation to quit, a cessation plan, and appropriate consent. And she cautions against reflexively pulling patients off JAKs for lipid changes—inflammatory AD can make lipid panels look artificially 'clean,' and controlling the disease often returns patients to their true physiologic lipid state, sometimes with increased LDL and HDL.
Looking Ahead—and Listening to the Patient
Cheever is excited about precision medicine, describing AD not as one disease but a collection of phenotypes and endotypes that respond differently to different therapies. She hopes the next five to ten years bring better prediction of which patient responds to which treatment before prescribing—less trial and error, more personalized selection—with continued focus on understanding the pathophysiology of itch.
Her closing advice: don't get lost in body surface area and severity scores. A low-BSA patient may be struggling profoundly, while some severe patients cope. She urges clinicians to ask about sleep, embarrassment, relationships, work productivity, the itch-scratch cycle, and especially the unpredictable nature of flares. Listening closely to how the disease affects a patient's life, she says, ultimately leads to the right treatment decision.