Matthew Zirwas, MD

The Top 5 Atopic Dermatitis Studies in the Past 2 Years, with Matthew Zirwas, MD

Top 5 Atopic Dermatitis Studies in the Past 2 Years, with Matthew Zirwas, MD

 studies have been published in the past 2 years, but which ones are the most useful to dermatologists?

At the 2025 New Wave Dermatology meeting in Aventura, Florida, Matthew Zirwas, a dermatologist at Bexley Dermatology, presented the most useful dermatology journal entries in the past year.

 He reviewed dermatologic uses for metformin, potential mechanisms of pimozide in delusions of parasitosis, ways to boost JAK inhibitor response in alopecia totalis, and treatments for burning mouth syndrome.

sat down with Zirwas at the meeting to discuss these highlights and his other talk on how to streamline the 

first 4 visits when diagnosing spongiotic dermatitis

. He also shared his picks for the top 5 atopic dermatitis studies published in the past 2 years.

“There have been some incredibly interesting new things, especially around atopic dermatitis,” Zirwas said. “[The most important finding is] that we are terrible at diagnosing it. As dermatology providers, we misdiagnose 2 out of 3 people who have atopic dermatitis. Instead of calling it atopic dermatitis, we're diagnosing it as dermatitis, unspecified. That needs to stop.”

Zirwas explained that adult atopic dermatitis is often misdiagnosed because the wrong criteria are used. While the Hanafin and Rajka criteria from the 1980s work well for children, they fall short in adults. Instead, he said dermatologists should follow the American Academy of Dermatology guidelines.

The difference lies in pathogenesis: genetics drive pediatric atopic dermatitis, but skin damage underlies adult cases. Zirwas pointed to toluene diisocyanate (TDI), a chemical in car exhaust and nylon and polyester clothing, as a major factor for skin damage.

“That explains why atopic dermatitis has been becoming more common, particularly since the 1970s, because the 1970s car exhaust changed to start to have this TDI in it, and that was because they put catalytic converters on cars,” Zirwas said. “Second, nylon and polyester became much more common in clothing, and residual TDI in nylon and polyester clothing is the other big driving factor for this acquired atopic dermatitis.”

Variation in clinical presentation of pediatric-onset and adult-onset atopic dermatitis: a retrospective, single-center, chart review of adults with atopic dermatitis from the United States

This retrospective review compared clinical features of adult- vs pediatric-onset AD. Adults had less flexural involvement and more nummular eczema and extensor surface involvement, with fewer personal or family histories of atopic disease.

Exposure to isocyanates predicts atopic dermatitis prevalence and disrupts therapeutic pathways in commensal bacteria

This study identified diisocyanates as strong predictors of atopic dermatitis. These chemicals disrupt beneficial lipid production and therapeutic modeling of 

 and commensal Staphylococcus. Diisocyanates demonstrated a temporospatial and epidemiological association with atopic dermatitis.

The 2023 Annual Report of DataDerm: The database of the American Academy of Dermatology

DataDerm, the American Academy of Dermatology’s massive dermatology database, included data from 14.2 million unique patients and 53.5 million visits in 2022. This report analyzed longitudinal care patterns for common dermatologic conditions, with emphasis on skin cancer.

Cohort studies on 71 outcomes among people with atopic eczema in UK primary care data

Using UK primary care data, investigators compared 3.6 million people with eczema to 16.8 million controls. They found eczema was strongly associated with hodgkin's lymphoma, alopecia areata, Crohn Disease, urticaria, coeliac disease, ulcerative colitis, autoimmune liver disease, and irritable bowel syndrome.

Association of air pollution and genetic risks with incidence of elderly-onset atopic dermatitis: A prospective cohort study

A UK Biobank study found both air pollution and genetics independently increased the risk of elderly-onset AD, but pollutants had a stronger effect than genetic predisposition.

Other useful dermatology journal entries published in the past 2 years that Zirwas presented are reported 

Relevant disclosures for Zirwas include Galderma Laboratories, L.P, Regeneron Healthcare Solutions, GENZYME CORPORATION, Arcutis Biotherapeutics, Lilly USA, Novartis Pharmaceuticals Corporation, Dermavant Sciences, LEO Pharma, Verrica Pharmaceuticals, Incyte Corporation, AbbVie, and PFIZER.

Zirwas M. The Most Useful Journal Articles of the Last 2 Years. Presented at the 2025 New Wave Dermatology at Aventura, Florida.

Munayco Maldonado G, Foy V, Tai H, Chiesa Fuxench ZC. Variation in clinical presentation of pediatric-onset and adult-onset atopic dermatitis: a retrospective, single-center, chart review of adults with atopic dermatitis from the United States. 

. 2024;316(7):409. Published 2024 Jun 15. doi:10.1007/s00403-024-03008-x

Zeldin J, Chaudhary PP, Spathies J, et al. Exposure to isocyanates predicts atopic dermatitis prevalence and disrupts therapeutic pathways in commensal bacteria. 

. 2023;9(1):eade8898. doi:10.1126/sciadv.ade8898

Van Beek MJ, Swerlick RA, Daveluy S, et al. The 2023 Annual Report of DataDerm: The database of the American Academy of Dermatology. 

. 2024;91(5):904-909. doi:10.1016/j.jaad.2024.05.096

Matthewman J, Schultze A, Strongman H, et al. Cohort studies on 71 outcomes among people with atopic eczema in UK primary care data. 

. 2024;15(1):9573. Published 2024 Nov 6. doi:10.1038/s41467-024-54035-1

Gu X, Jing D, Xiao Y, et al. Association of air pollution and genetic risks with incidence of elderly-onset atopic dermatitis: A prospective cohort study. 

. 2023;253:114683. doi:10.1016/j.ecoenv.2023.114683

Videos

Zirwas shares top dermatology studies, highlights AD misdiagnosis, and reveals how pollution and fabrics may trigger adult-onset atopic dermatitis.

The First 4 Visits When Treating Spongiotic Dermatitis, With Matthew Zirwas, MD

Diagnosing spongiotic dermatitis relies on ruling out other dermatologic diseases. At the 2025 New Wave Dermatology meeting in Aventura, Florida, Matthew Zirwas, MD, a dermatologist at Bexley Dermatology, broke down what the first 4 visits for diagnosing 

HCPLive sat down with Zirwas at the meeting to discuss these 4 visits, what dermatologists should do in situations where a patient has a non-specific rash, and when a wood lamp should be used to find the area to scrape in scabies.

“Whenever a new patient presents with spongiotic dermatitis, it can be overwhelming because we're so used to thinking about it in terms of: what are all the different things that could be doing this? Could it be contact dermatitis? Could it be atopic dermatitis? Could it be scabies? Could it be CTCL? Could it be dermatitis unspecified? What the heck is going on?” Zirwas said. ‘It really helps to have an almost algorithmic approach where you say, ‘Okay, first visit,’ and this is really the way that I think about it.”

Breaking the steps into 4 visits helps make the diagnosis more manageable, easier to see. During the first visit, Zirwas said you should assume your patient has contact dermatitis and get them away from any potential contact allergen, such as soaps or moisturizers. A patient should be treated as if they do have this contact dermatitis, whether that is with a topical or systemic steroid.

Patients could be treated with either clobetasol/moisturizer mix QD M-F, moisturizer only on Saturday and Sunday; 720 fexofenadine in the morning, consider 20 mg cetirizine in the evening; strontium cream or pramoxine cream for PRN use; and oral ceramide, oral probiotic (10 Strain), and melatonin 5-10 mg. You should see this patient anywhere between 4 to 8 weeks later to see if the medication improved their symptoms.

“If they are like, ‘Oh my God, it all cleared up. I don't even need to use that cream anymore.’ Great, it was contact DERM,” Zirwas said. “You can decide if you want to patch tests in to try and figure out what it was, or if you want to just let them continue to use low allergenicity products.”

Zirwas said you could consider tapering cetirizine or making steroid topical PRN if a patient does well after the treatment regimen.

However, if a patient is not dramatically better at that second visit, then you should assume the patient has atopic dermatitis and treat accordingly. Patients could be treated with mirtazapine 15 mg qhs if they want a sleep aid and duloxetine 30 mg qhs if they don’t need help with sleep. Zirwas recommends stopping topical steroids and antihistamines. Dermatologists should explain that mirtazapine, an old antidepressant, is not for depression but for itch nerve endings. During his presentation, Zirwas said mirtazapine was the most effective oral medication he has seen for itch.

If treatment for atopic dermatitis did not work by the third visit, 3 – 4 months later, that is when you may consider dermatologic conditions, such as unusual contact dermatitis, scabies, or CTCL. You could also switch a patient from mirtazapine to duloxetine or vice versa. You could also consider a commercial tanning bed (3-5 times a week for 20 visits) or in-office NBUVB. Patients who are getting better could go to a commercial tanning bed 1 – 2 times a week, long-term.

At this point, Zirwas said you should strongly consider a biopsy or a comprehensive patch test and then wait for the fourth visit. If the biopsy does not show CTCL or scabies, you should assume the patient has atopic dermatitis again and try alternative atopic dermatitis. You should also stop mirtazapine or duloxetine and consider gabapentin or pregabalin.

“We can only really be sure about what type of dermatitis it is by seeing what results in the patient getting better,” Zirwas said. “And so, [during] each of those visits, there's a different [one] we're going to try. We're going to try this if that didn't work, we're going to try this. If that didn't work, we're going to try this….it really does make for the most efficient way to conduct the visits and get the patients better.”

Zirwas, M. The First 4 Visits in the Itchy Patient. Presented at the 2025 New Wave Dermatology meeting in Aventura, Florida, on May 17, 2025. 

Zirwas outlines a 4-visit approach to diagnosing spongiotic dermatitis, helping dermatologists manage uncertain rashes more effectively.


We’ve had a great conversation about treating atopic dermatitis. We all see a lot of patients. What I’d like to do is ask each of you: In your practice in dealing with these patients, do you have some kernels of truth that you’ve relied on that have helped set your patients up for success, or something you can give our audience that they can take back and utilize to have the best possible outcomes? Matt, I’m going to start with you.

 Linda, I’m going to give you the spiel that I give a patient once I’ve gotten through disease education and we’re now selecting therapy. I’m a believer that setting them up for success means shared decision-making so that they’re not taking what I think they should be on, they’re taking what they think they should be on. It can be really simple. I believe that shared decision-making needs to be really simple: 2 options, at most 3 bullet points per option.

Here’s my spiel: “Luckily for you, we have great options now, they’re not steroids, you’re going to stay on them long term. I’m going to give you some choices, and you’re going to tell me which one sounds better. First, we can treat you with a pill. It’s going to start working in 2 or 3 days, but it does weaken your immune system. Or we could give you a shot that starts working in a week or two but does not weaken your immune system. You have to keep giving yourself a shot every 2 weeks or once a month. So again, a pill works that in a couple days, no shots but weakens your immune system, or a shot every 2 weeks that starts working in a week or two and does not weaken your immune system. Which one sounds better to you?”

Most patients have a very clear either, “I couldn’t imagine giving myself a shot” or “I wouldn’t want to do anything that might weaken my immune system.” If they say pill, then I’m going to talk about the boxed warning. “I do have to tell you it’s going to have some things that sound really scary.” The advice I have for everybody is when you’re talking about the boxed warning, don’t start with heart attack, stroke, death, and cancer. Start with, “Some things sound really scary. The data we have about this medication haven’t shown an increased rate of these things. But the FDA wants you to know about them because a different medication used in people who don’t have eczema that’s distantly related to this medication did slightly increase the chances of these scary things. But again, for this medication, none of the information we have about it has shown an increased rate.”

I do want you guys to know and our viewers, I didn’t say it doesn’t increase the rate. I said the information we have has not shown any increased rate. I said scary things a couple of times. I’ve said distantly related medication, people who don’t have eczema. Then I say, “The scary things, just so you’re not surprised when you get it, are things like heart attacks, strokes, and blood clots, and cancer. But again, all the information we have about this medication has not actually shown an increased rate of those things happening.” That makes people more comfortable with the JAK [inhibitors], and I don’t feel like I’ve said anything inaccurate. If that was taped and played in court, everything I said was right, and I stand behind everything I said. My pearl is shared decision-making and how I talk about the JAK boxed warnings.

 It makes me think about a quote that is often attributed to Confucius. It might be apocryphal because people attribute a lot of quotes to Confucius. But it’s, “Because the newer treatments are good, it does not follow that the old ones were bad. For if our worshipful and honorable ancestors had not recovered from their ailments, you and I would not be here today.” But they are really nice, and to have some new treatments and be able to talk about these with our patients has changed the game. I think this is the beginning of a new era in atopic dermatitis. We can now promise things and deliver in a way that we’ve never been able to before. I’m really excited about this, and also excited to see where it’s going.

 I would add that the patients who present to our office who are most undertreated are still those moderate patients. I would say my pearl would be looking, as we’ve all said today, at the patient holistically, not just the BSA [body surface area] of that patient on one day and time but considering other factors like the impact of itch. Sometimes I look at something called the BSA of itch, where you’re saying, “Your skin disease is 5% today, but where are you itchy? How is this impacting your life?” The moderate patients are as impacted quality of life-wise by their disease as our severe patients, if you look at the studies. So, make sure you are presenting your options.

I like what Aaron said, even when you have a mild patient in the office, I often say, “You look good today, but I want to show you the runway, which is very different than it was 5 or 10 years ago. If your disease control is to change, if your satisfaction about your treatment or something about your life is to change, if your disease is to change in some ways, I want you to know that other treatments exist.” Because for so many years for these patients, they didn’t. Still, I think there’s lack of awareness of our advanced therapies for atopic dermatitis. It’s capturing the moderate patients, it’s getting all of our patients to higher levels of disease control. I agree with Peter, I feel so lucky to take care of these patients in the year 2023, and I think we’ll only feel that amplified in the years to come.

This has been a fantastic discussion. I think we’ve all learned from each other. I want to thank each of you for this informative discussion. And I want to thank you all for watching this 

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Experts in dermatology share practice pearls and takeaways for treatment of atopic dermatitis.

Pearls for Atopic Dermatitis Management

Aaron, I’m going to come back to you. We have all these wonderful tools, but we know if the patient doesn’t do what we’re hoping they’re going to do, that turns out to be a problem. What do you find, how do you assess that, how do you keep them on track?

Patient adherence is critical in this disease, and there are good data already out there, most recently one paper looking at insurance claim data as well as diagnosis between 2017 and 2019. We recognized that topicals are still the most commonly used treatment. They didn’t dive in exactly into which topicals, but we know that when you get to greater levels of efficacy and you move into the biologics as well as the JAK inhibitors, you’re going to have improved adherence because you’re also going to have better efficacy. It is difficult with these patients with the overall mindset of “I’m better.” As Peter was saying, when do we stop these treatments and these therapies? It almost doesn’t matter what we have to say, it’s what the patients are going to do.

As we get new treatments that work really quickly, I’ve seen some patients adjusting the way they are utilizing these therapies. It’s our job to educate our colleagues, as well as our patients, that this is a lifelong disease, although hopefully not. There is some question about disease modification that’s getting even more exciting, but we don’t have time to discuss that today. Adherence is of course of the utmost importance and making sure this fits into the patient’s daily life.

Ali, do you have any special tricks or tips you use to make sure the patient stays on task?

 I find my [patient] visits in atopic dermatitis sometimes are opposite to those in psoriasis because a lot of the patients with atopic dermatitis are less familiar with the chronic and systemic nature of their disease. Atopic dermatitis is a chronic, and for most patients, a lifelong systemic, inflammatory disease. The conversation about long-term control, and in some cases the need for systemic control-long term, becomes easier when they understand their disease as inflammation that’s going on underneath the surface even when they feel better. When they can accept it as a systemic condition, just like we understand many ailments in medicine, that conversation about systemics—like if you stop insulin in a diabetic, your diabetes would still be there–it becomes easier to understand.

I always say, “Let’s get you clear and then we’ll reassess.” That needle might move, and that’s due to some of the exciting things coming through the pipeline. But for now, setting them up to say, “This is a great time to have atopic dermatitis. For the first time, I can offer you something safe for you to stay on long term that is going to get you to a better level of control.” It was not something we could say before. It’s made that conversation much easier.

 That’s an important point. Patients present to us in a variety of different ways. I’m finding now some obviously are presenting 

, new with disease, and so we’re able to get these better treatments to them earlier. Sometimes the discussion is easier with a patient who has had atopic dermatitis for 10 years, and for whatever reason they weren’t offered or maybe they didn’t consider some of these other more advanced treatments. It’s sort of a different discussion with each of these patients.

 It’s a disease state re-education. A point that Matt brought up, which I completely agree with, is that flare anticipation. It’s not only the parents feeling desperate that they can’t manage their child’s atopic dermatitis, it’s that adult patient saying, “Why can’t I get this under control? Why can’t I just be clear for a while?” It’s saying, “because it’s out of your control. This is completely not dictated by that allergy you’re trying to find, but because it’s a systemic disease.” Once that acceptance happens, I feel like the conversation becomes easier. That dominates a lot of my initial visit time and is why I run behind all the time.

Expert dermatologists discuss treatment discontinuation as a barrier to achieving desired outcomes in atopic dermatitis.