Mona Shahriari, MD, FAAD

This video segment synthesizes long-term safety data for JAK inhibitors and biologics, highlights the risks of undertreated inflammation, and closes with practical “art of medicine” pearls for selecting and tracking therapy in atopic dermatitis.

Special Report: Safety, Future Directions, & the Art of Therapy Selection in Atopic Dermatitis

Long-term safety considerations are central to decisions about initiating and continuing advanced systemic therapies in 

In this video, host Mona Shahriari, MD, notes that several years of clinical trial and real-world data with upadacitinib now support its use in diverse patient subgroups, including individuals who smoke, use hormonal contraception or hormone replacement therapy, or have cardiovascular risk factors. She stresses that adverse events of special interest—such as malignancy, major adverse cardiovascular events, and venous thromboembolism—must be interpreted in the context of baseline risk inherent to the general and atopic dermatitis populations. Current data suggest that rates of such events with JAK inhibitors in atopic dermatitis appear broadly consistent with background rates, which helps her counsel patients and colleagues with greater confidence.

 on switching therapeutic classes in atopic dermatitis, expert guest Andrew Mastro, MS, PA-C, underscores the importance of correlating real-world evidence, such as the CorEvitas-type data sets, with clinical trial outcomes to validate both efficacy and safety expectations during therapy switches. The discussion then turns to recent long-term safety data for tralokinumab, which report rates of major cardiovascular events, thromboembolism, and malignancy that are comparable to those observed with upadacitinib. Mastro explains that while these findings did not change his personal practice—because he already viewed these agents as viable long-term options—they provide valuable reassurance for clinicians and patients who may have been hesitant about JAK inhibitors. Shahriari distills this into a practical message: if a clinician is comfortable with the long-term safety of tralokinumab, they should feel similarly comfortable with upadacitinib when used in appropriately selected patients.

The segment broadens to address the risk of not treating atopic dermatitis aggressively enough. Shahriari emphasizes that uncontrolled inflammation is not benign and that atopic dermatitis is associated with systemic comorbidities, including cardiovascular disease and other inflammatory conditions. She frequently discusses this with parents of pediatric and adolescent patients who may be reluctant to start systemic therapy, explaining that persistent, moderate to severe disease is unlikely to “just go away” and that appropriately selected systemic treatment may mitigate long-term consequences. Mastro describes the “light bulb” moment when patients realize their disease is more than “just an itchy patch,” and how connecting internal inflammation to external manifestations facilitates acceptance of injectable or oral therapy. The discussion concludes with practical pearls: Mastro reminds clinicians to see “a person in the room with a problem,” not just a diagnosis, and Shahriari offers a simple “ART of medicine” framework—assess burden beyond BSA, pick the right mechanism of action, and track response using AHEAD recommendations. 

Relevant disclosures for Shahriari include AbbVie, Apogee, Arcutis, Bristol Myers Squibb, Dermavant, Galderma, Incyte, Johnson & Johnson, LEO, Lilly USA, Novartis, Regeneron, Sanofi-Genzyme, Takeda, UCB, Pfizer, and others. Mastro has no relevant disclosures to report.

Silverberg JI, Gooderham M, Katoh N, et al. Combining treat-to-target principles and shared decision-making: International expert consensus-based recommendations with a novel concept for minimal disease activity criteria in atopic dermatitis. 

Silverberg JI, Bunick CG, Hong HC, et al. Efficacy and safety of upadacitinib versus dupilumab in adults and adolescents with moderate-to-severe atopic dermatitis: week 16 results of an open-label randomized efficacy assessor-blinded head-to-head phase IIIb/IV study (Level Up). 

Videos

Explore the long-term safety and efficacy of JAK inhibitors in atopic dermatitis, enhancing patient care and clinician confidence.

This segment addresses the multifactorial causes of therapeutic inertia in atopic dermatitis and outlines practical scripts for discussing JAK inhibitor safety, boxed warnings, and risk–benefit considerations with patients.

 Special Report: Overcoming Therapeutic Inertia and Communicating Safety of JAK Inhibitors

Therapeutic inertia is a recurrent challenge in the management of moderate to severe 

Mona Shahriari, MD, suggests that inertia often stems from clinician comfort with “good enough,” time pressures, and residual uncertainty about newer therapeutic classes such as JAK inhibitors. She notes that until 2017 there were no targeted agents combining high levels of skin clearance with long-term safety suitable for chronic use, which shaped expectations for what was considered acceptable control. Now, with advanced biologics and JAK inhibitors available, she argues that continuing to prioritize convenience over optimal outcomes can inadvertently shortchange patients whose lives might be transformed by deeper disease control.

 on switching therapeutic classes in atopic dermatitis, both Shahriari and expert guest Andrew Mastro, MS, PA-C, emphasize the critical role of communication in mitigating therapeutic inertia. Mastro describes reframing safety conversations so that they are proactive, structured, and time-efficient, rather than a barrier to prescribing. Shahriari shares a concise script she uses when discussing JAK inhibitors: she acknowledges that pursuing greater efficacy and speed of response may involve additional risk, explains her plan for baseline laboratory evaluation, and contextualizes boxed warnings by clarifying that they derive from a different drug in a different disease population with additional immunosuppressive therapies. She reassures patients that, based on their individual medical history, she does not anticipate a heightened risk but invites them to contact her if anything feels concerning once treatment starts.

Mastro complements this with his “three Ps” framework—emphasizing that the situation in which the boxed warning arose is not the same person, problem, or prescription as the atopic dermatitis patient and agent under consideration. He briefly reviews the surveillance study that generated the warning, highlights differences in population and indication, and then explicitly explains why he believes those data do not directly translate to the current atopic dermatitis scenario. Both clinicians stress that these conversations can be conducted in 1 to 2 minutes yet have a profound impact on patient trust, adherence, and willingness to switch. 

Healthcare providers discuss the importance of effective communication when switching patients from biologics to JAK inhibitors.

Special Report: Overcoming Therapeutic Inertia and Communicating Safety of  JAK Inhibitors

This segment examines how to define inadequate response in atopic dermatitis, operationalize treat-to-target concepts, and interpret data from the LEVEL UP trial on switching from biologic to JAK inhibitor therapy.

Special Report: Inadequate Response and When to Switch Systemic Therapy in Atopic Dermatitis

Determining when to maintain, optimize, or switch systemic therapy in 

 requires a nuanced understanding of treatment targets, patient expectations, and evolving evidence.

In this video, expert guest Andrew Mastro, MS, PA-C, describes his approach to defining inadequate response by integrating objective thresholds and patient-reported outcomes. He views a failure to achieve deeper responses—such as EASI 90, IGA 0/1, and near-complete itch control (NRS 0–1)—by approximately 4 months on a biologic as a signal that optimal targets have not been met, especially for moderate to severe disease. He distinguishes primary failure (never achieving moderate or deeper levels of response) from secondary failure (loss of previously adequate control, increased flares, or greater day-to-day disease awareness) and emphasizes that patient dissatisfaction must accompany clinician concern for a switch to be appropriate.

 on switching therapeutic classes in atopic dermatitis, host Mona Shahriari, MD, builds on this framework with a discussion of therapeutic inertia and the importance of not remaining indefinitely at “good enough.” She notes that while some patients may justify longer trial periods, such as 9 months, the AHEAD recommendations explicitly suggest considering a switch if treat-to-target goals are not achieved within 3 to 6 months. Shahriari likens earlier efficacy benchmarks to “first-generation robots” that were impressive at the time but limited in capability; in contrast, contemporary data support aiming for EASI 90 or even EASI 100 and near-complete itch suppression to meaningfully improve quality of life, sleep, and psychosocial outcomes.

A key evidence base discussed is the LEVEL UP study, which evaluated switching from dupilumab to upadacitinib. Shahriari describes the two-period design, beginning with a head-to-head comparison of upadacitinib and dupilumab, where upadacitinib demonstrated superiority at week 16 on a composite endpoint of EASI 90 plus near-complete itch control. The second phase focused on patients with inadequate response to dupilumab (defined as not reaching EASI 75) who then switched to upadacitinib 15 mg. Remarkably, within 4 weeks of switching, nearly 7 in 10 of these prior nonresponders achieved EASI 75, about one-third reached EASI 90, and many had started from a baseline of roughly EASI 50 at the time of switch. These findings reinforce that failure on one advanced therapy does not preclude robust response to another mechanism of action.

Clinicians discuss the importance of patient-centered treatment decisions and the need to address therapeutic inertia in managing chronic conditions.

This segment reviews the modern systemic treatment landscape in atopic dermatitis and discusses how the AHEAD recommendations and tools like ADCT can support treat-to-target care.

Special Report: Treat-to-Target in Atopic Dermatitis—Applying the AHEAD Recommendations

The systemic treatment landscape for moderate to severe 

 has shifted from broad immunosuppression to targeted therapies supporting both short-term control and long-term disease modification.

In this video, host Mona Shahriari, MD, contrasts historical reliance on nonselective immunosuppressants, which often had challenging safety profiles, with current options that include biologics and JAK inhibitors offering higher efficacy thresholds and more favorable long-term safety. She frames the central clinical question as, “What is the end game?” and introduces the AHEAD treat-to-target recommendations as a framework for defining what “good” long-term control should look like, beyond simply being “better than baseline.”

 on switching therapeutic classes in atopic dermatitis, Shahriari explains that AHEAD is a global consensus initiative encompassing approximately 100 clinicians from 44 countries, designed to raise the standard of atopic dermatitis care worldwide. The recommendations set ambitious targets within 3 to 6 months of therapy initiation, emphasizing high levels of both clinician-reported and patient-reported outcomes. Targets include EASI 90, IGA 0/1, and low body surface area (BSA) involvement on the clinician side, and nearly complete resolution of itch on patient-reported scales. Expert guest Andrew Mastro, MS, PA-C, highlights how these treat-to-target thresholds align clinical expectations with patient goals and embed shared decision-making into routine care rather than treating it as an optional add-on.

Mastro then discusses practical implementation using both traditional measures (IGA, BSA, itch numeric rating scale) and the Atopic Dermatitis Control Tool (ADCT). He notes that ADCT can be embedded in electronic medical records and administered by support staff or via tablets before the visit, providing a six-item, 30-second assessment of symptoms, sleep, mood, and overall bother. Shahriari echoes her preference for ADCT and adds that she often supplements objective metrics with a direct question about whether patients are satisfied with their current level of control or wish it were better. This simple phrasing can uncover residual disease burden in individuals who may fear losing partial gains if therapy is changed. 

Explore the evolving landscape of atopic dermatitis treatment, focusing on advanced therapies and long-term patient management strategies.

Mona Shahriari, MD, FAAD

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