Personalizing Atopic Dermatitis Treatment in a Growing Landscape: April Armstrong, MD, MPH

At the Winter Clinical Dermatology Meeting, April W. Armstrong, MD, MPH, professor and chief of dermatology at the UCLA Department of Dermatology, discussed how clinicians can navigate a rapidly expanding treatment landscape for atopic dermatitis.

In this interview with The American Journal of Managed Care^® (AJMC^®), she highlights considerations for therapy selection, long-term safety data for JAK inhibitors, and emerging approaches that could further transform care.

This transcript was lightly edited for clarity.

AJMC: With multiple targeted therapies now available for atopic dermatitis—including JAK inhibitors, IL-13 inhibitors, and biologics—how are you approaching treatment selection in clinical practice? Are there particular patient phenotypes or disease characteristics that guide you toward one class over another?

Armstrong: In clinical practice, treatment selection is increasingly individualized based on disease severity, symptom burden, comorbidities, and patient preferences. For patients with a high itch burden or who need rapid disease control, oral JAK inhibitors can be attractive because of their speed of onset, though they can also be appropriate for a broader range of patients depending on disease severity, comorbidities, and treatment goals.

IL-13–targeted biologics are often a good option for patients seeking durable control with a favorable long-term safety profile, particularly those who prefer less frequent dosing. I also consider factors such as comorbid asthma, prior treatment response, and patient comfort with oral versus injectable therapies when making decisions together with the patient.

AJMC: You discussed long-term safety data for JAK inhibitors such as upadacitinib and abrocitinib. How should clinicians interpret these findings—especially around cardiovascular events or malignancy risk—when counseling patients who may already have underlying risk factors?

Armstrong: When interpreting long-term safety data for JAK inhibitors, it’s important to consider the overall context of the patient population being treated. In dermatology trials, many of the patients are younger and have fewer baseline cardiovascular risk factors than populations studied in rheumatology, where some of the earlier safety signals emerged. In long-term studies that are specific to JAK inhibitors in the atopic dermatitis population, we have thus far seen reassuring safety profiles.

In my counseling, I review a patient’s individual risk profile, such as age, smoking status, cardiovascular disease history, or prior malignancy, and discuss how those factors may influence therapy choice. Shared decision-making is key, and for many patients, the potential benefits in disease control and quality of life can outweigh theoretical risks when monitored appropriately.

AJMC: Your presentation raised the question of whether endpoints like EASI-90 alone truly capture meaningful clinical response. Do you think we’re moving toward more multidimensional definitions of “deep response” that incorporate patient-reported outcomes like itch or quality of life?

Armstrong: Yes, I do think the field is moving toward a more multidimensional definition of response. While EASI-90 is a valuable and objective measure of skin improvement, it does not fully capture symptoms that matter most to patients, such as itch, sleep disruption, and quality of life. In both clinical trials and real-world practice, we are increasingly incorporating patient-reported outcomes like itch scores or dermatology quality-of-life indices to better understand treatment benefit. Ultimately, the goal is not just clear skin, but meaningful improvement in how patients feel and function in their daily lives.

AJMC: Data from registry studies suggest that some patients with well-controlled disease may be able to taper biologic therapy. How realistic is dose reduction in everyday practice, and what criteria should clinicians use to decide when to attempt it?

Armstrong: Dose reduction can be considered in select patients who have achieved stable disease control, ideally complete skin clearance, for a sustained period of time. In practice, I usually look for patients who have been clear for at least six months or longer, have minimal to no itch, and are not experiencing frequent flares. Even then, tapering needs to be approached cautiously and with close follow-up, since some patients may relapse when treatment intervals are extended. Shared decision-making and careful monitoring are essential, and not every patient will be an appropriate candidate for dose reduction.

AJMC: Looking beyond currently approved therapies, which emerging mechanisms or agents in the pipeline do you think have the greatest potential to change how we manage atopic dermatitis over the next few years?

Armstrong: Several emerging pathways are quite promising and reflect how rapidly the field is evolving. We’re seeing development not only of agents targeting upstream immune pathways but also next-generation biologics such as bispecific or even trispecific monoclonal antibodies, which may allow more precise modulation of key inflammatory signaling beyond a single target. These therapies remain targeted, but by engaging multiple pathways, they may better address the biological heterogeneity we see in atopic dermatitis while still maintaining favorable safety profiles.

There is also increasing interest in small-molecule approaches, including oral STAT pathway inhibitors, as well as therapies that influence neuroimmune signaling. Over the next few years, I expect the therapeutic landscape to continue expanding, giving clinicians more options to tailor treatment based on individual patient biology, disease characteristics, and treatment goals.