Panel Confronts Access, Documentation Gaps in Atopic Dermatitis Care

More than half of adults with severe atopic dermatitis (AD) report inadequate disease control, and patients average 9 flares a year lasting 15 cumulative days of disrupted sleep, school, and work. Even as treatment options multiply, dermatology clinicians said, the path from topical steroids to systemic therapy is shaped less by clinical guidelines than by a patient's insurer, zip code, and practice staffing.

That tension anchored a Washington, DC, Population Health Roundtable hosted by The American Journal of Managed Care^® on July 21, 2026, where clinicians discussed systemic and operational barriers to AD care and escalation of therapy beyond topical treatment. The discussion was moderated by Ginette A. Okoye, MD, FAAD, professor and chair of the Department of Dermatology at Howard University College of Medicine.

The panel drew physicians, nurse practitioners, and physician assistants from Howard University, Children's National Hospital, George Washington University, the University of Maryland, and Johns Hopkins Medicine, spanning academic, pediatric, and military dermatology practice.

Undertreatment Persists Despite an Expanding Toolbox

Okoye opened by noting that AD affects an estimated 40% of adults and 33% of children with moderate to severe disease, and that itch remains the most burdensome symptom. She cited data showing topical treatments still account for roughly two-thirds of prescription volume despite better adherence to biologics and that only 44% of patients with moderate to severe AD have ever received an advanced systemic therapy.

Joy Wan, MD, MSCE, assistant professor of dermatology at Johns Hopkins University School of Medicine, said the hardest patients to manage now are those who don't respond adequately even to the newest therapies, often pushing clinicians toward off-label combinations in younger children who have fewer FDA-approved systemic options. Robert Smith, MD, assistant professor of dermatology at Johns Hopkins, added that AD visits are "very energy-intensive and time-consuming," much of it spent "undoing a lot of misinformation related to atopic dermatitis."

Insurance and Staffing Shape Who Reaches Systemic Therapy

Leonardo Tjahjono, MD, FAAD, an assistant professor of dermatology at George Washington University, said DC Medicaid carries the highest burden in his practice, with a biologics coordinator sometimes spending an hour on the phone with 1 plan before a patient reaches second-line therapy. Kevin Sharghi, MD, assistant professor of dermatology at Johns Hopkins, based at Sibley Memorial Hospital, said prior authorization wait times through his institution's specialty pharmacy have doubled in recent months, with a single nurse absorbing the overflow.

Smith described a stark urban-rural divide, saying patients who travel hours from Maryland's Eastern Shore reliably present with the most severe disease. Charlotte Lanphear, PA-C, of University of Maryland Dermatology, said insurance-driven step therapy complicates even well-informed plans. "If I had all the time in the world and all the money in the world, the thing that I would do tomorrow morning is go to the Maryland Medicaid office and be like, we have to shut you down," she said, describing patients pushed through nonsteroidal step therapy before reaching biologics now approved for children as young as 2.

Documentation Tools Weren't Built to Capture Disease Burden

Sharghi, who also serves as his department's health IT lead, said clinicians largely use free-text AD assessments, with wide variability by training level, and that patient-reported outcome tools such as Patient Oriented Eczema Measure scores are integrated seamlessly into clinical trials he worked on but not into commercial electronic medical records. A. Yasmine Kirkorian, MD, chief of the Division of Pediatric Dermatology at Children's National Hospital, said her system pushes some patient surveys to "a random PDF in a file" that no one reviews.

Carolyn Stolte, CRNP, of University of Maryland Dermatology, who trained in the institution's Itch Clinic, said itch numeric rating scores carry real meaning for patients but “don’t seem to mean anything to insurance," which wants "something more finite" than a description of scratching at work. Kirkorian added that disease burden in skin of color can be disproportionate to what a clinician sees on exam, since dyspigmentation can be disfiguring even when inflammation looks mild, and Tjahjono said he now biopsies more AD cases after catching several patients with underlying cutaneous T-cell lymphoma.

Panel Weighs Fixes: Dashboards, Coordinators, and Patient Education

Asked what single change each would bring back to their institution, Kirkorian pointed to her system's dashboard that flags patients before a prior authorization lapses, saying a similar tool for patients lost to follow-up could catch high-risk cases earlier. Tierra Hurd, PA-C, of Johns Hopkins, said her priority is standardizing education around tapering long-term topical steroid use, while Sharghi said dedicated support staff, such as a therapist or social worker embedded in the clinic, could offset the counseling time clinicians don't have in 15-minute visits.

Smith tied the discussion's threads together, saying the fee-for-service system "doesn't reward complexity" and instead favors procedural, adult-focused care over the counseling-heavy work AD demands. "They're following the rules of the game," he said, "and the rules of the game that we've established as a system don't reward the care of sick patients."