Clinicians Chart the Barriers That Keep Atopic Dermatitis Undertreated

More than half of adults with moderate to severe atopic dermatitis (AD) report inadequate disease control, yet only 44% of those with moderate to severe disease have ever received an advanced systemic therapy. The gap between what dermatology can offer and what patients actually receive keeps widening. Biologics and oral agents are proliferating; meanwhile, insurance design, documentation practices, staffing shortages, and hesitancy on both sides of the exam table keep care escalation out of reach.

That tension was threaded through 4 Population Health Roundtables hosted by The American Journal of Managed Care during the summer of 2026: Philadelphia, Pennsylvania, on June 4; Boston, Massachusetts, on June 16; Washington, DC, on July 21; and Chicago, Illinois, on August 6. The discussions were moderated, respectively, by Susan C. Taylor, MD, FAAD, professor of dermatology at the Perelman School of Medicine, University of Pennsylvania; Erik Domingues, MD, FAAD, assistant professor of dermatology at UMass Chan Medical School; Ginette A. Okoye, MD, FAAD, professor and chair of the Department of Dermatology at Howard University College of Medicine; and Walter J. Liszewski, MD, associate professor of dermatology at Northwestern University Feinberg School of Medicine. Each panel gathered dermatologists, advanced practice providers, and pharmacists from academic centers, children’s hospitals, and private practices, and although the rooms were separated by hundreds of miles, they returned strikingly
similar conclusions.

‘Good Is Not Great’

The most consistent theme across the 4 cities was that undertreatment hides in plain sight. In Philadelphia, Nicholas Mollanazar, MD, MBA, assistant professor of clinical dermatology at the University of Pennsylvania, recounted learning that approximately 70% of patients who qualify for an advanced systemic therapy are not receiving one—a figure he initially dismissed until he began questioning his own patients who were scheduled as routine topical refills and found many were ready to escalate.

“Patients do suffer in silence,” Mollanazar said. “I think we get jaded because there are so many people who flood our inboxes with messages that they are not doing well, so we think that is what everyone is going to do.”

Boston panelists described the same quiet settling. “Some of our patients are used to [their condition] just being good, but good is not great,” said Yasin Damji, MD, an attending physician in the dermatology program at Boston Children’s Hospital. Damji argued that clearance and freedom from itch are now realistic goals that patients should not be talked out of.

In Chicago, Sarah Chamlin, MD, professor of pediatric dermatology at Northwestern University Feinberg School of Medicine and Ann & Robert H. Lurie Children’s Hospital of Chicago, cautioned that some apparent treatment failures are, in fact, undertreatment in another form. She asks every patient’s parent who says they have tried everything how big their tube of topical steroid is and when it was last refilled. “Nine times out of 10, it’s [not that big], and they haven’t refilled it in 2 months,” Chamlin said, adding that going back to basics reveals which children truly need systemic therapy—and that families who escalate often wish they had done so sooner.

Documentation Rarely
Captures Severity

If undertreated patients are often invisible, the panelists agreed, it is partly because the severity of their condition is rarely documented. “Over 95% of all encounters do not capture any disease severity until the point of submission for an advanced systemic, and that is where we are lacking [the most] as a specialty,” Mollanazar said, noting that dermatology cannot even say what proportion of its patients have moderate to severe disease. He tied the documentation gap to the specialty’s resistance to care pathways: “In dermatology, it is still the wild, wild west. We let people do kind of what they want.” The consequence, he warned, is that “the insurance [companies] right now are telling us what to do because we are not coming out with clearer guidelines.”

The Washington panel described the same mismatch from the clinic side. Carolyn Stolte, CRNP, of University of Maryland Dermatology, said the itch scores, which matter to patients, “don’t seem to mean anything to insurance,” which wants “something more finite” than a description of a patient scratching. In Chicago, Anthony Mancini, MD, professor of dermatology and head of the Division of Dermatology at Lurie Children’s Hospital and Northwestern University Feinberg School of Medicine, offered a workable middle ground in the Patient-Oriented Eczema Measure (POEM), kept on paper in all of his clinics. “I love the POEM,” Mancini said, crediting it both for smooth insurance authorizations and for showing families their progress.

Insurance Hurdles and Hidden Costs

Step therapy and prior authorization drew the sharpest frustration in every city. Bridget Cange, PharmD, a clinical pharmacist at Tufts Medical Center in Boston, described navigating authorizations as “a maze [we’re] trying to figure out.” In Washington, Charlotte Lanphear, PA-C, of University of Maryland Dermatology, described building a shared decision with a family, only to have the plan rewritten by a payer.

The Chicago panelists flagged a newer cost trap: co-pay maximizer plans, which allow manufacturer co-pay cards to be exhausted without ever counting toward a patient’s deductible. Maximizer plans are becoming more common, “and patients don’t know that they’re on them,” said Stefanie Cisek, PharmD, clinical team lead pharmacist at Northwestern Medicine Specialty Pharmacy, adding that stranded patients often return asking for the cheapest generic option rather than the safest, best one.

The burden falls hardest on publicly insured patients. Leonardo Tjahjono, MD, FAAD, assistant professor of dermatology at George Washington University, told the DC panel that fewer and fewer practices in the district accept Medicaid at all, and that his biologic coordinator often spends an hour on the phone with a single Medicaid plan just to secure a first-line biologic—delays that compound for patients juggling multiple jobs who cannot make the calls themselves.

Robert Smith, MD, assistant professor of dermatology at Johns Hopkins University School of Medicine in Baltimore, Maryland, noted that these behaviors are rational responses to fee-for-service incentives that reward procedures over complex medical management. “They’re following the rules of the game,” Smith said of colleagues who avoid complex patients, “and the rules of the game that we’ve established as a system don’t reward the care of sick patients.”

Hesitancy on Both Sides of the
Exam Table

Even when access is secured, escalation can stall in the exam room. Chase Kwon, MD, a dermatologist at Derm Institute of Chicago, said he has watched some colleagues mischaracterize newer medications such as dupilumab as “horrible immunosuppressive agents” that patients are committed to for life. Panelists in Boston and Washington likewise described patients arriving with steroid fears, needle phobia, and years of misinformation to undo.

The remedy, several said, is simpler framing and lower-stakes commitments. Mollanazar has pared his biologic counseling down to a physical metaphor: “Your body is a scale. You have severe eczema. It is out of balance, and the biologic is meant to bring it back into balance.” Saira Agarwala, MD, a dermatologist at Temple Dermatology in Philadelphia, asks hesitant patients to commit only to a trial period, telling them, “If in 3 months you do not like it, we can do something else. It does not have to feel like your decision is permanent.”

Building the Infrastructure to Close the gap

When escalation works, panelists said, it is because institutions have built infrastructure around it. “I don’t think I would [be able to] practice without the Northwestern specialty pharmacy,” said Steve Xu, MD, MSc, a dermatologist at Northwestern Medicine. Temitayo Ogunleye, MD, professor of clinical dermatology at the University of Pennsylvania, said pharmacy check-ins that flag lapsed prescriptions have been “amazing for continuity.” The support is not evenly distributed, however. Joy Wan, MD, MSCE, assistant professor of dermatology at Johns Hopkins University School of Medicine, told the DC panel that specialty pharmacy wait times at her institution have doubled in recent months, with a single nurse left to absorb the overflow of prior authorizations and the counseling that 15-minute visits cannot hold.

Paras Vakharia, MD, PharmD, assistant professor of dermatology at Northwestern University Feinberg School of Medicine, argued the bigger unmet need is upstream of any prescription: getting patients with severe disease “into the room” faster, the way expedited slots already work for patients with suspected skin cancers.

Penn Medicine has begun testing that triage logic by sharing standardized eczema plans with a telemedicine urgent care service that manages low-acuity patients and escalates severe cases to dermatology. “It was a clear way to triage the low-acuity patients out and make sure that we are seeing only the highest acuity,” Mollanazar said.

The closing note in Philadelphia doubled as a challenge to all 4 meetings, most of which were filled with clinicians from well-resourced academic centers. Zelma Chiesa Fuxench, MD, MSCE, associate professor of dermatology at the University of Pennsylvania, urged colleagues to design for the solo dermatologist in a care desert as much as for themselves: “Whatever it is that we build, try also thinking ahead of: Can this be implemented in a way that works for someone who does not have any of the resources that we have?”