A Specialty Without a Playbook
Panelists were candid about the absence of standardized care pathways for AD—an absence that contrasted sharply with disciplines such as oncology, cardiology, and rheumatology, which use disease-specific algorithms to guide and constrain clinical choices. "In dermatology, it is still the wild, wild west," Mollanazar said. "We let people do kind of what they want." He described working with the American Academy of Dermatology (AAD) on electronic medical record (EMR) order sets modeled on oncology workflows, in which initiating a biologic would automatically populate drug-specific initiation and maintenance protocols along with recommended laboratory monitoring.
AAD clinical guidelines were characterized as too hedged to offer meaningful direction. "The insurances right now are telling us what to do because we are not coming out with clearer guidelines," Mollanazar said. He called for guidance that identifies preferred first-line advanced systemic options for patients with moderate to severe AD inadequately controlled on topicals, rather than language that lists all available agents without prioritization. Chiesa Fuxench acknowledged the tension in that approach, noting that more prescriptive sequencing could inadvertently hand payers a framework for codifying step-therapy requirements.
Insurance Barriers and the Medicare Access Problem
Prior authorization requirements and step-therapy mandates were a through-line in the discussion. Panelists with access to dedicated specialty pharmacy teams—including full-time pharmacists managing prior authorizations, appeals, and patient education—described this infrastructure as essential to practice function. In private practice settings, the burden of prior authorization fell on medical assistants and, ultimately, on clinicians.
Medicare patients were identified as a particularly challenging subgroup. Mollanazar described a recurring pattern in which patients with Medicare were approved for dupilumab or lebrikizumab but declined to initiate treatment because of concerns about a one-time out-of-pocket cost—approximately $2000—arising from Medicare Part D benefit design. "They are nervous about what they are signing up for, payment-wise," he said, noting he was developing patient-facing educational materials to address the issue. Medicaid patients, by contrast, were described as generally easier to initiate on therapy, with faster approvals and no cost burden.
Variability in co-pay assistance programs was raised as a growing concern. Charli Drialo, PA-C, noted that some patients who had successfully initiated biologic therapy later lost access when manufacturer assistance programs changed abruptly, making out-of-pocket costs unmanageable. "That has become more of a barrier in the last couple of months," she said.
Initiating Biologics and Addressing Hesitancy
Panelists shared concrete strategies for moving patients past hesitancy and practical barriers to biologic initiation. Mollanazar described using an accessible framing with patients: "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." He deliberately deferred detailed dosing information to written materials and pharmacy follow-up, allowing patients to concentrate on mechanism and likely side effects during the clinic visit.
Saira Agarwala, MD, told hesitant patients to focus only on the next 3 months: "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." Emily Hejazi, MD, MS, added that clarifying the mechanics of subcutaneous injection—specifically, that patients do not need to identify a vein and that the autoinjector conceals the needle—was often enough to move patients forward. Several participants noted that hands-on injection training, either through pharmacy staff or in the clinic, meaningfully improved both patient confidence and long-term adherence.
The Pharmacy Team as Linchpin
Across institutions, specialty pharmacists were recognized as the most critical postinitiation support resource. Temitayo Ogunleye, MD, described how proactive pharmacy check-ins caught patients whose prescriptions had lapsed, bridging them with short-term medication supplies until they could be seen in clinic and preventing the flares and potential hospitalizations that could follow a treatment gap. "That has been like amazing for continuity," she said.
Mollanazar described a new pilot program at Penn Medicine that embedded shared AD treatment plans into a telemedicine internal medicine practice, enabling non-dermatologist providers to manage lower-acuity cases and triage more severe presentations directly to dermatology. In its first week, the program managed 15 patients with AD and identified 3 who required escalation to systemic therapy. "It was a clear way to triage the low-acuity patients out and make sure that we are seeing only the highest acuity," he said.
Taking Action
As the roundtable concluded, participants named concrete steps they intended to bring back to their institutions. Standardized EMR order sets were identified as among the most feasible and highest-impact near-term improvements. Chiesa Fuxench called for scalable solutions that extend beyond academic medical centers to private practices and underserved regions, where a single dermatologist may serve an entire community. "Whatever it is that we build," she said, "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?"
The overarching challenge, participants agreed, is not a shortage of effective treatments. It is a shortage of the infrastructure, standardized data collection, and cross-institutional coordination needed to ensure those treatments reach the patients who need them most.
