Escalation of Atopic Dermatitis Care Requires Addressing Barriers

Atopic dermatitis affects an estimated 16.5 million adults and nearly 10 million children in the US, and more than half of adults with moderate to severe disease report inadequate control.¹ Chicago-area dermatologists and pharmacists said escalation from topical to systemic therapy is often slowed less by clinical evidence than by which specialty pharmacy a patient can reach, whether an insurer imposes a co-pay maximizer plan, and how comfortable a physician is prescribing a biologic.

That tension anchored the Chicago Population Health Roundtable, hosted by The American Journal of Managed Care^® on August 6, 2026, where clinicians examined barriers to treatment escalation. The discussion was moderated by Walter J. Liszewski, MD, associate professor of dermatology at Northwestern University Feinberg School of Medicine, who noted that topicals still account for roughly two-thirds of AD prescription volume despite greater adherence to biologics, and only 44% of patients with moderate to severe disease have received an advanced systemic treatment.

The panel drew adult and pediatric dermatologists and specialty pharmacists from Northwestern Medicine, the Ann & Robert H. Lurie Children's Hospital of Chicago, the University of Chicago, Illinois Dermatology Institute, and community practices across the area.

Documentation Practices Vary, and Payers Want More Than Gestalt

Gaurav Agnihotri, MD, a dermatologist at the University of Chicago, said there is “still a lot of variety” in how physicians document AD severity, even within 1 academic center; he tracks body surface area, a 1-to-10 itch score, and sleep impact, but nothing is standardized. Anthony Mancini, MD, professor of dermatology at Northwestern Feinberg and division head of dermatology at Lurie Children's, said he uses the Patient-Oriented Eczema Measure (POEM) for every patient started on a systemic agent: “I love the POEM. It's quick and dirty.”

Stefanie Cisek, PharmD, clinical team lead pharmacist at Northwestern Medicine Specialty Pharmacy, said her wish list starts with body surface area “and then description of impact on quality of life, whether that be sleep, itch, or excoriation leading to scabbing.” Renewals depend on documented improvement, although patients who feel better often skip follow-up. Liszewski now documents Investigator's Global Assessment severity rather than “mild, moderate, or severe,” so records are “teed up as well as possible for getting drugs covered.”

Clinician Hesitancy and Topical Underuse Slow the Move to Biologics

Chase Kwon, MD, a community dermatologist with the Derm Institute of Chicago, said he has encountered colleagues who “conflate newer medications like dupi [dupilumab] as these horrible immunosuppressive agents that you're committed to for the rest of your lives.” Liszewski said the pattern persists even where safety data exist: “It's really up to the individual and what they feel comfortable doing.”

On dupilumab's reported ocular adverse events, Sarah Chamlin, MD, professor of pediatric dermatology at Northwestern and Lurie Children's, questioned the reports: “Who knows if it's true.” Cisek said data behind the Janus kinase (JAK) inhibitors' boxed warnings are “not robust at all,” since the pivotal comparison was against a tumor necrosis factor inhibitor rather than a placebo. More often, patients labeled biologic failures simply had not used enough topical steroid; Chamlin asks parents how big their tube is and when it was refilled: “Nine times out of 10, it's this big, and they haven't refilled it in 2 months.”

Specialty Pharmacy Access and Payer Barriers Decide Who Reaches Advanced Therapy

Liszewski said he no longer starts most patients on dupilumab, favoring lebrikizumab (Ebglyss; Eli Lilly), citing data that more than half of lebrikizumab patients maintained a response after stopping treatment vs about a third on dupilumab. Steve Xu, MD, MSc, a Northwestern Medicine dermatologist, said he could not imagine practicing without the in-house specialty pharmacy. Kwon, previously in rural Chillicothe, Ohio, said patients there had the most severe AD cases he’d seen in his career and far less help securing biologic therapies.

Cisek described co-pay “maximizer” plans, which exhaust manufacturer assistance without reducing a deductible, leaving bills as high as $3500 per fill: “Patients don't know that they're on them.” Outside pharmacies, she said, often redirect patients to “the cheapest generic oral that is not going to be the safest or best option for them.” Agnihotri linked coverage pressure to thin staffing elsewhere: “A lot of these specialty pharmacies are people working from their house. They are not together.”

Paras Vakharia, MD, PharmD, assistant professor of dermatology at Northwestern, said the bigger unmet need is getting severe patients into the clinic at all, since expedited-appointment triggers do not yet flag severe eczema the way they flag a bleeding mole; getting them “into the room” is the real bottleneck. Mancini credited Chamlin, the group's clinical practice director, with spending “probably over a year” building decision trees in Epic that let schedulers triage referrals without a clinician.

Asked what they could implement within 18 months, Vakharia proposed a department-wide documentation template for atopic dermatitis; Cisek suggested extending it to psoriasis, hidradenitis suppurativa, and alopecia. Liszewski said Northwestern was already building those templates to make sure “there's consistency” across inflammatory skin diseases, regardless of which physician saw the patient.