Stable Long-Term Control of Atopic Dermatitis Is Within Reach with Biologic Therapies

Long-term control of atopic dermatitis (AD) symptoms remains elusive, but providers who manage this condition are closer than ever to achieving stable, durable results thanks to significant progress in the treatment of inflammatory skin conditions. Early intervention, along with careful consideration of individual patients’ goals, are key to achieving sustained improvement, according to a panel of experts who discussed biologic therapies for the treatment of AD at the 2025 Fall Clinical Dermatology Conference in Las Vegas. 

Atopic dermatitis is a chronic, inflammatory skin condition characterized by widespread lesions, which can vary in appearance and location based on age and phenotype. Patients with AD experience intensely itchy flare-ups, which have a significant impact on sleep and quality of life. A significant proportion of patients with AD are young, as onset often occurs in early childhood. “I get more aggressive [in the treatment of] kids because it affects so many different things in their lives, it affects their sleep, their ability to develop well in school, to pay attention in class,” said Marc Serota, MD, a pediatric immunologist and dermatologist. “If their skin is on fire all night, they are not sleeping well. The price of not treating atopic dermatitis is missed sleep.” Providers typically see only a snapshot of the disease during visits, and they may need to use an objective measure such as the eczema area and severity index (EASI) score to get a more complete picture of its impact on patients’ lives. 

The pathophysiology of AD involves enhanced expression of cytokines produced by innate immune cells, including interleukin (IL)-13, IL-4, and IL-31. Multiple biologic therapies that were designed to target these cytokines have shown promise in controlling the symptoms and flares of AD over long periods of time. Data from clinical trials and real-world studies showed high rates of treatment success and maintained responses with various biologic therapies. Dupilumab, a biologic agent designed to block IL-4 and IL-13, achieved an EASI-75 score in 72% of responders by week 16 in a real-world setting. Tralokinumab and lebrikizumab, which target IL-13, and nemolizumab, which blocks IL-31, showed similar efficacy results. In the ECZTEND open-label, long-term extension study, 71% of patients who took tralokinumab maintained a stable therapeutic response up to week 152. Clinical trial data also showed that 82% of patients treated with lebrikizumab maintained EASI-75 response up to week 52. 

Ongoing instability and high symptom burden should prompt initiation of biologic therapy, to achieve a deep and stable response to treatment. The goal of treatment should always be long-term control of AD, Serota said. “I tell patients I am not curing their disease, I am putting it in the background,” he added. 

While all biologic therapies have shown promise for controlling AD long-term, multiple factors, including comorbidities, frequency of dosing, and route of administration, guide the choice of therapy in clinical practice. “When you walk into an [exam] room, which one of these do you present to the patient in the context of a 5-minute conversation?” Serota asked. “First, you need to know that these exist, second, you need to know which ones you pick for a certain job. There are different tools for different jobs.” 

In the current therapeutic landscape, biologics therapies are used as the first-line treatment for AD. Janus kinase (JAK) inhibitors, which have also demonstrated efficacy for the treatment of AD, are typically reserved for patients who are not candidates for biologic therapies, due to a higher risk of adverse events. 

“You really can’t trust your eyes alone anymore if you want to treat eczema patients correctly,” said Shawn Kwatra, MD, professor and chair of the department of dermatology at the University of Maryland School of Medicine.” You have to look at the rash and then also ask them [about their] itch score, from 0 to 10. I think that is the big learning point, having that conversation at an earlier timepoint and getting both metrics. In all trials, the primary endpoint is the EASI score, but we have to go by the patient’s primary point, which is the itch.” While the appearance of skin may be normal in some patients, it may look different under the microscope. Asking patients about their symptoms is key to optimal management, Kwatra noted, reminding the audience that the impact of AD symptoms on quality of life cannot be overemphasized. AD is a disease that affects the entire family, with some patients equating its impact to the burden of cancer or diabetes. While systemic therapies are widely used for AD, patients also receive topical therapies, to use as needed in combination with systemic agents. 

Providers now have a way to gauge an ideal response to biologic therapies, which translates into clear skin and controlled pruritus. “At week 16, I want your skin to be 75% better,” Serota explained. “We have at least a 75% chance of achieving that with any of these drugs.” An Investigator's Global Assessment (IGA) score of 0, along with EASI-90 to EASI-100 scores, are the true home runs for patients with AD, Serota added. If none of those metrics are met by week 16 after treatment initiation, providers should ensure that patients adhere to therapy, and that they have received the correct diagnosis. 

Stability of response means hitting a plateau in disease, where patients no longer experience flares. As illustrated by the clinical trial data, therapeutic responses are likely to be maintained long-term with all biologic therapies. Steroids, which have traditionally been the cornerstone of treatment for AD, are associated with significant risks when used long-term, as is cyclosporine, which is still used in clinical practice for AD. “We have biologics in our toolbox for atopic dermatitis,” Serota said. “Once we get stable [responses], we get to keep them stable over the long run. You have to counsel patients that [these therapies are] designed to put your disease in the background, to jam the radio signals, rather than curing the disease.” If treatment stops, patients may revert to the previous level of disease activity, although some children may grow out of AD. Providers should check in with patients at regular intervals, to monitor response to therapy. 

The two experts agreed that one challenging part of AD management is communicating safety concerns associated with the biologic therapies to patients. Injection site reactions and conjunctivitis have been shown to occur in approximately 10% of patients treated with dupilumab and 7% of those treated with tralokinumab, while patients treated with nemolizumab have reported headaches. Patients should be counseled about the likelihood of these events, while emphasizing the improvements in itch and inflammation and the long-term efficacy of these therapies, Serota added. Biologic therapies have a more favorable risk profile than immunosuppressants and steroids, and they are approved for use in children. While early intervention is crucial for sustained treatment response, ultimately, patients’ goals regarding symptoms, dosing frequency, and long-term effects should guide the choice of therapy for AD.