Q&A: How Is Treatment Selection Changing in Atopic Dermatitis?

The rapid expansion of treatment options for atopic dermatitis has transformed clinical decision-making, giving dermatologists more tools than ever to individualize care while introducing new questions about treatment selection, sequencing, and long-term disease management.

As biologics, Janus kinase (JAK) inhibitors, and advanced topical medications continue to reshape dermatology’s therapeutic landscape, clinicians are increasingly balancing efficacy, safety, patient preferences, and quality-of-life considerations when developing personalized treatment plans.

In this interview with HCPLive, conducted on-site at the Revolutionizing Atopic Dermatitis (RAD) Conference in Nashville, Walter Liszewski, MD, an associate professor of dermatology and cancer epidemiology at Northwestern University Feinberg School of Medicine, highlights the evolving approach he explored in his session to selecting treatments for patients with atopic dermatitis.1

In this Q&A interview, Liszewski shares his perspective on choosing between oral and biologic agents, the growing role of advanced topical drugs, managing patients after treatment failure, and how emerging biomarkers and long-term real-world evidence may help clinicians deliver increasingly personalized care in the years ahead:

HCPLive: In your session at RAD, you focused on treatment selection across oral, biological, and topical options in atopic dermatitis. With more approved options in atopic dermatitis than ever before, has treatment selection gotten easier or more complex for the practicing dermatologist?

Liszewski: It's gotten a little bit more complicated, only in the sense that we have more options available. This is a great thing for patients, because we have the ability to let patients control the conversation. Do they want an oral option? Do they want an injectable? What side effects are tolerable to them? How important is it to control how quickly it works?

Having more options available allows us to provide better care and allows patients to be more empowered. The other thing is that it gives us more options where things fail. That was part of one of my talks. Although we have great medications and have great therapies, not everyone responds, so having a backup plan or multiple backup plans is really helpful.

HCPLive: How do you think about the oral versus biologic decision in a field where the safety conversation around JAK inhibitors is continuing to evolve?

Liszewski: It's complicated. I do think that oral options like JAK inhibitors can be incredibly effective. However, the way that they're currently positioned, due to FDA labeling, is that they need to be used when a patient is found to have a systemic agent. So, are there patients who would benefit from starting with a JAK inhibitor as their first advanced agent? Absolutely, but unfortunately, that's not something we can do. We do have more and more safety data about JAK inhibitors. I think there's really starting to be a turn within the dermatology practice. I think many providers are starting to feel more comfortable using JAK inhibitors. I think we're going to see more momentum, more utilization in the coming years.

HCPLive: The emergence of advanced topicals has expanded the toolkit. Should dermatologists be incorporating them rather than defaulting to what they already know?

Liszewski: Using advanced therapies can be very effective, and it's important to remember atopic dermatitis exists across the spectrum of mild, moderate, and severe, and sometimes those are fluid in patients. We do know that atopic dermatitis is a long-term chronic condition. For some patients, short-term use of topical steroids can be effective, particularly if their disease doesn't flare. That often tends to be very mild, but for some patients who have more chronic disease that don't necessarily qualify or need a biologic, that's where these advanced therapies are great.

But what's really exciting is we know even when we use advanced therapies, our oral agents or biologics, not everyone gets completely clear. We can still have hotspots that are active areas that are very bothersome, either cosmetically or in terms of itching patients. That's where we can leverage and utilize advanced therapies that have safer long-term utilization in combination with advanced therapies. It is really the next step in managing atopic dermatitis.

HCPLive: Sequencing after treatment failure is one of the murkier areas in atopic dermatitis management. How do you approach that decision, and what does the evidence actually support?

Liszewski: Yeah, this is kind of the wild west. So, we have case reports, and we have individual experiences. For me, if someone's failed a biologic in a JAK, and this is what I talked about in my presentation, it's really challenging because we don't really have a backup option right now. We do have things in the pipeline that potentially, in the next 1 or 2 years, may give us a different mechanism of action. Things like the OX-40s. Currently, though, we have a variety of options. One is to utilize a biologic or JAK inhibitor in combination with phototherapy.

It's a little bit of an insurance nightmare, but using a biologic with a JAK inhibitor, and there is some evidence for escalating JAK inhibitors above the standard atopic doses, particularly for drugs like upadacitinib, which do have higher 45 milligram dosing. There is evidence for using those for long-term or short-term control in patients who fail current FDA-approved concentrations for atopic dermatitis.

HCPLive: How much patient preference and quality of life priorities? Let's say. Driving treatment selection, and is the field doing enough to sort of center that? Would you say in clinical decision making?

Liszewski: I haven't been in practice that long. I've only been in practice now for about 8 years, but not that long ago, when I was in residency, we never really talked about itch in atopic dermatitis. Since then, there's really been a major change in conversation with our patients who are asking about itch and how they feel. I think we've really seen a major shift in terms of how we're incorporating patient symptoms and how we can control the RPs.

I think we're going to continue to see more utilization not only about asking but also sometimes for using patient-reported outcome measures. Things like a POM score or just routinely asking about NRS-Itch or NRS-Sleep can really help us better understand the symptoms our patients are going through and whether or not our patients are being fully controlled. Not only in terms of skin clearance, but also in terms of symptoms such as itch or pain or insomnia or anxiety.

HCPLive: Looking at where the evidence gaps still are, what would you say is most helping practicing dermatologists make more confident, individualized decisions for their atopic dermatitis patients?

Liszewski: I think that because we have more therapies, we're starting to see more data, and also just real-world use of trying different drugs, which patient populations do well with one but not another. I think we're still figuring that out. We are starting to see the beginnings of utilization of biomarkers commercially to identify and segment patients. I think there's going to continue to be refinement and improvement in that, and I think when that is at a very high level, highly successful, then hopefully we'll have an ability to routinely personalize medications based on a patient's genetic need. Excellent,

HCPLive: How do you think the treatment selection conversation will change as long-term real-world data continues to mature?

Liszewski: I think it's going to, in many ways, maybe make it a little bit more difficult because as we have more data, there's more we need to review, and for patients, there's a lot they have to digest. So having more data is a good thing. It helps us know long-term what the safety maturity is. What is this long-term X? Is it durable? So having more data that shows that these drugs are effective long-term, that there's continued improvement over time, is helpful. It's also very reassuring.

The more extension trial safety data we have, because these medications are long-term medications. So knowing what the long-term side effects are. On the flip side, it's a lot more that we have to review with our patients. But ultimately, the more data we have, the more we can empower our patients to make the decision that's right for them.

Disclosures: Liszewski did not have any relevant disclosures of note.

References

1. Liszewski W, Rubin C, Cotter D, et al. Session 4: Medical Crossfire® and Clinical Case Challenge. Session presented at: 2026 Revolutionizing Atopic Dermatitis Conference; June 17-19, 2026; Nashville, TN.