Clinicians Weigh Insurance Barriers and Hesitancy in Atopic Dermatitis Care

The newest biologics and oral therapies can clear moderate to severe atopic dermatitis (AD) within months, yet many patients who qualify for them never begin, held back by insurance requirements, fear of injections, and a long-held belief that chronic itch is something to live with. That gap between what dermatology can offer and what patients actually receive framed a population health roundtable hosted by The American Journal of Managed Care^® as part of its Institute for Value-Based Medicine^® series in Boston, Massachusetts, on June 16, 2026.

Erik Domingues, MD, FAAD, assistant professor of dermatology at UMass Chan Medical School and founder of Modern Dermatology of Massachusetts, moderated the discussion. Dermatologists, physician assistants, and clinical pharmacists from Boston Children's Hospital, Boston Medical Center, Tufts Medical Center, and private practice examined why patients with AD so often remained on regimens that were not working and what their institutions could do to change that.

AD affects an estimated 16.5 million adults and more than 1 in 10 children in the US.^1,2 Roughly 40% of adults with the disease have moderate to severe involvement, and more than half of adults with a history of moderate to severe AD have inadequately controlled disease on their current treatment.³ Those figures, panelists said, understated the problem, because many patients never reported how poorly they were doing.

Patients Who Settle for Good Enough

Panelists described a population that had grown accustomed to disease. Yasin Damji, MD, an attending physician in the dermatology program at Boston Children's Hospital, said many patients accept partial improvement because they know nothing else. “Some of our patients are used to just being good, but good is not great,” he said, adding that clearance and freedom from itch have become realistic goals.

Misinformation compounds the problem. Molly A. Stout, MD, FAAD, a dermatologist at SkinCare Physicians in Chestnut Hill, said patients often refuse topical steroids because of misinformation about their safety and hesitate over systemic options even as effective treatments multiplied. Damji added that patients frequently confuse the warnings they hear in television drug commercials with the biologics used for AD, a fear that direct education could ease.

Documenting a Burden That Often Goes Unmeasured

Capturing disease severity emerged as an uneven practice. At Boston Children's Hospital, every patient seen for eczema completes a Patient-Oriented Eczema Measure (POEM), a validated patient-reported severity measure, through the patient portal or on paper.⁴ The score gives clinicians an objective metric before the visit and supports prior authorization. Lynda C. Schneider, MD, director of the allergy program and the Atopic Dermatitis Center at Boston Children's Hospital and associate professor of pediatrics at Harvard Medical School, said her center pairs POEM with additional quality-of-life and disease-control measures.

Private practices report fewer structured tools and often rely on history alone. Margaret S. Lee, MD, PhD, FAAD, director of pediatric dermatology at Boston Medical Center, urged colleagues to ask routinely about sleep as a quick window into quality of life. She also noted that severity in patients with skin of color was often underrecognized because AD is harder to assess in darkly pigmented skin, a difficulty other panelists echoed.

Insurance, Not Guidelines, Drives Treatment

Several participants said that no formal care pathway guided the management of moderate to severe AD and that insurance requirements often determined the sequence of therapy. Bridget Cange, PharmD, a clinical pharmacist at Tufts Medical Center, said building a framework is difficult when each plan imposed different rules. “It's like a maze trying to figure it out,” she said, describing prior authorizations required at nearly every step, including for older topicals such as tacrolimus.

Domingues said he asks about each patient's insurance up front because Medicaid patients often had to try and fail 3 to 5 topical steroids before qualifying for advanced therapy. Panelists also flagged coverage instability, noting that an agent preferred on December 31 could become nonpreferred on January 1.

Moving Patients Past Hesitancy and Coordinating Care

Needle phobia was a recurring obstacle, particularly in pediatrics. Damji said he sometimes uses patients' steroid aversion in favor of a biologic, framing it as a safe, steroid-sparing option. Lee said addressing needle phobia was her institution's greatest unmet need and that a nursing team administered injections for younger patients whose families were uncomfortable giving them at home, while an interdisciplinary coping clinic with a pediatric psychologist helped older children.

Across settings, the panelists credited pharmacy teams as the element that held treatment together, reviewing specialty prescriptions, counseling patients, and working prior authorizations and appeals. Lee described an e-consult service that let pediatricians flag children for prompt dermatology visits. Julia A. Siegel, MD, a dermatologist at Boston Dermatology and Laser Center, said she delegated prior authorizations to specialty pharmacies that were motivated to secure approval because they would go on to fill the medication.

The panelists agreed that effective treatments existed. The harder task, they said, was building the documentation, coordination, and access support needed to connect those treatments with the patients who needed them.

References

1. Chiesa Fuxench ZC, Block JK, Boguniewicz M, et al. Atopic dermatitis in America study: a cross-sectional study examining the prevalence and disease burden of atopic dermatitis in the US adult population. J Invest Dermatol. 2019;139(3):583-590. doi:10.1016/j.jid.2018.08.028

2. Shaw TE, Currie GP, Koudelka CW, Simpson EL. Eczema prevalence in the United States: data from the 2003 National Survey of Children's Health. J Invest Dermatol. 2011;131(1):67-73. doi:10.1038/jid.2010.251

3. Wei W, Anderson P, Gadkari A, et al. Extent and consequences of inadequate disease control among adults with a history of moderate to severe atopic dermatitis. J Dermatol. 2018;45(2):150-157. doi:10.1111/1346-8138.14116

4. Charman CR, Venn AJ, Williams HC. The patient-oriented eczema measure: development and initial validation of a new tool for measuring atopic eczema severity from the patients' perspective. Arch Dermatol. 2004;140(12):1513-1519. doi:10.1001/archderm.140.12.1513