Moving Past the Band-Aid Era
PA Buchi Neita and PA Shanna Miranti open by acknowledging that atopic dermatitis (AD) hasn't always had a comfortable therapeutic window, but they argue we're now in a 'golden era' of treatment. As Miranti puts it, whether you see peds, adults, or a mix of ages, you’ll see AD in everyday practice.
Before diving into newer options, the hosts revisit the old-school systemics: cyclosporine, methotrexate, and prednisone. They're candid that oral steroids are still widely prescribed both in and outside of derm, and that patients often ask for 'just the shot' because a cortisone injection held them over in the past.
Neita reframes that request for clinicians and patients alike: the steroid shot was a band-aid and a short-term reduction in symptoms. As she says, 'if we're going to put a needle in your body, let's put something that's way safer.' Both hosts agree there may still be an important role for methotrexate, cyclosporine, and oral steroids, but the field is moving away from them.
The Biologic Game Changers
The hosts remind providers that biologics typically end in '-mab' (monoclonal antibodies) and work as cytokine blockers targeting specific inflammatory pathways. Dupilumab was first to market, blocking IL-4 and IL-13. Miranti calls it a game changer that has been life-changing for many patients, and notes it carries the lowest age indication at six months and older.
Beyond skin control, the hosts highlight added benefits described for dupilumab: evidence of a 32% reduction in the risk of the atopic march (potentially preventing asthma and environmental allergies in babies started early), plus a decreased risk of infections — not just the typical atopic staph skin infections but even upper respiratory infections.
Next came tralokinumab and lebrikizumab, both IL-13-specific agents. Miranti notes tralokinumab offers decreased dosing to every four weeks after loading for patients doing well, and is approved down to 12 years. Lebrikizumab, the 'new kid on the block' among IL-13s, reportedly has a higher binding affinity to IL-13. The hosts emphasize the clean labels: similar side effect profiles (injection site reactions, conjunctivitis/eye irritation), no lab monitoring, and quick same-day initiation if samples are available.
Nemolizumab, initially approved for prurigo nodularis and then for AD, targets IL-31 — long known as the 'itch cytokine.' Miranti clarifies its mechanism is a relatively weak block at the IL-31 receptor, but it delivers very rapid itch relief, with some patients reporting complete relief within 24 hours. She flags the unusual 'rocket ship'–looking autoinjector that requires mixing the ingredients before injection and letting it rest, urging clinicians to try the demo devices.
Oral Small Molecules: The JAK Inhibitors
The hosts turn to the two JAK inhibitors currently approved for AD: upadacitinib and abrocitinib. Miranti loves these agents for patients who need very fast relief, noting they work well and work fast, with abrocitinib reportedly showing head-to-head data against dupilumab suggesting slightly faster results.
They stress that JAK inhibitors require more front-end work: lab monitoring and thorough counseling about the black box warning. Choosing the right patient matters — screen for chronic kidney disease, any history of cancer, serious infection. Done appropriately, the hosts describe these as phenomenal and highly effective.
Both hosts emphasize shared decision-making, especially with teenagers (both agents are indicated 12 and up). As Neita frames it to patients: would you rather take a shot every two weeks or once a month with minimal else, or take a pill every day? For healthy patients who've had the proper workup, the oral option can be attractive, and JAK inhibitors may offer a quicker leg up on itch.
On the Horizon
The hosts preview several pipeline agents. Delgocitinib, a topical pan-JAK inhibitor in clinical trials, is anticipated for chronic hand eczema. Miranti likes that its pan-JAK mechanism addresses not only type 2 inflammation but also other cytokines like IL-17 that can show up in CHE. Both hosts note the importance of distinguishing true chronic hand eczema — sometimes the only site involved — from contact dermatitis and other mimics.
They also mention phezicinumab, an IL-22 inhibitor in clinical trials, noting IL-22 has been associated with impaired barrier function and changes in the skin microbiome. As a cytokine blocker, it works outside the cell and would be delivered by injection.
The agents Neita is most excited about are the OX40 ligand antagonists. OX40 is overexpressed in AD and helps drive type 2 inflammation; by targeting memory T cells, these agents are reportedly producing dramatically clear skin and long-term remission even after stopping the medication. Both hosts describe this mechanism as very different from anything currently available.
Counseling, Compliance, and Support
The hosts close on best practices. They point clinicians and patients to the National Eczema Association (nationaleczema.org) and the EczemaWise app, which lets patients track symptoms, triggers, flare photos, and medications in one place.
Set realistic expectations: AD is a chronic disease that won't be cured, but can be controlled so patients live a normal life without constant itch. Keep the regimen simple — the more you prescribe, the less patients do — and write down the order of steps (e.g., apply medicine first after shower, then moisturizer). Miranti's practical tip: have patients photograph the written instructions in the room, because they'll lose the paper half the time.
Finally, give patients access. The hosts recommend using patient portals for open communication and close follow-up, especially early in management, noting patients still want that hand-holding and VIP-level care.