Clinicians Confront Fragmented Care and the Silent Burden of Undertreated Atopic Dermatitis

Atopic dermatitis (AD) has more treatment options today than at any point in the history of dermatology. It also has a treatment gap that, by some estimates, leaves 70% of patients who qualify for advanced systemic therapy without it. That tension—between a rich therapeutic landscape and the systemic failures that keep it out of reach—animated a population health roundtable hosted by The American Journal of Managed Care^® (AJMC^®) in Philadelphia, Pennsylvania, on June 4, 2026.

Dermatologists, physician assistants, and a clinical pharmacist from the University of Pennsylvania, Temple Dermatology, Jefferson Health, and private practice gathered to examine the full arc of AD management, from identifying undertreated patients and navigating prior authorization to biologic initiation and long-term follow-up. Their conversation revealed a specialty with powerful tools and a system ill-equipped to deploy them.

Patients Who Suffer in Silence

AD affects approximately 16 million adults and nearly 10 million children in the US, and roughly 40% of adults and 33% of children have moderate to severe disease. Yet despite an expanding arsenal of biologics and Janus kinase inhibitors, panelists described patient populations that consistently fall through the cracks—not because effective therapies do not exist, but because the system is not designed to find them.

Karan Pandher, MD, described patients whose socioeconomic circumstances make even basic topical regimens untenable. "The toughest patients are those ones that have a difficult time adhering to a regimen because of the socioeconomic burdens that they may have," he said, adding that he often considers biologic therapy earlier for patients who cannot realistically apply ointments daily.

Nicholas Mollanazar, MD, MBA, recounted a pivotal conversation with a pharmaceutical executive who shared data suggesting that 70% of patients who meet criteria for advanced systemic therapy for AD are not receiving it. He initially dismissed the claim—until a refill clinic that same day changed his perspective. When he began asking patients requesting topical refills how often they actually used their medications, many reported applying them only 2 weeks out of every month and were open to discussing systemic therapy when asked directly. "Patients do suffer in silence," he said. "I think we get jaded because there are so many people that flood our in-boxes with messages that they are not doing well, so we think that is what everyone is going to do."

The group agreed that asking patients broadly how they are doing is insufficient. More direct questions—about topical use frequency, whether patients want to try something different, or whether they feel their disease could be better controlled—were identified as meaningfully more likely to surface unmet need.

Disease Severity Goes Undocumented

Capturing the full burden of AD in clinical practice emerged as a persistent gap. Zelma Chiesa Fuxench, MD, MSCE, described embedding validated tools—including the Patient-Oriented Eczema Measure, Investigator Global Assessment, and body surface area estimates—directly into her note templates to ensure consistent severity documentation. She acknowledged that this approach is not widely replicated.

Mollanazar put the scope of the problem plainly: "Over 95% of all encounters do not capture any disease severity until the point of submission for an advanced system, and that is where we are lacking [the most] as a specialty." Without structured data, institutions cannot identify what proportion of their AD population has mild, moderate, or severe disease, nor can they reliably track treatment response over time. Electronic health record infrastructure was cited as a compounding barrier—extracting severity data from narrative notes currently requires manual chart review.

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.