AAD Atopic Dermatitis Treatment Update: A Q&A With Linda Stein Gold, MD

Linda Stein Gold, MD

Provided by Dr Linda Stein Gold

Atopic dermatitis (AD) management continues to evolve with the rapid introduction of new treatment options. The American Academy of Dermatology (AAD) recently released a focused update to its guidelines for adults with AD, incorporating both novel topical agents and biologic therapies. In this Q&A, Linda Stein Gold, MD, director of dermatology clinical research at Henry Ford Health System, discusses the key updates and what they mean for primary care physicians. Stein Gold explains where newer topical agents such as tapinarof and roflumilast fit in, how biologics including lebrikizumab and nemolizumab compare with existing options, and what primary care physicians should know about safety, monitoring, and treatment selection.

The following transcript has been edited lightly for clarity and style.

Patient Care®: What are the key updates in the 2025 atopic dermatitis focused guidelines for managing adult atopic dermatitis patients that primary care physicians should be aware of?

Linda Stein Gold, MD: The good news is that the atopic dermatitis guidelines are pretty much a living document, which means they evolve with the state of dermatology. We recently had a focused update to incorporate new treatment options into the AAD guidelines for best practices in atopic dermatitis. Four drugs were evaluated: two topical medications and two systemic medications.

The first was tapinarof, a nonsteroidal topical agent and oral hydrocarbon receptor agonist. It is FDA approved down to age 2 and shown to be safe and effective for patients with moderate to severe atopic dermatitis. The second drug is roflumilast, a topical phosphodiesterase type 4 inhibitor, also nonsteroidal. This drug was FDA approved down to age 6, studied in patients with mild to moderate disease, and shown to be safe and effective.

Two biologic drugs were also evaluated and incorporated into the guidelines: lebrikizumab and nemolizumab. Lebrikizumab targets IL-13, one of the key cytokines in the pathogenesis of atopic dermatitis. It is given by injection and FDA approved down to age 12 for moderate to severe disease. We saw good efficacy, safety, and control of itch. After the initial period, injections can be spaced to every four weeks from every two weeks while maintaining efficacy. Even patients who went off drug maintained efficacy for up to 52 weeks.

Nemolizumab targets the IL-31 receptor, known as the itch cytokine. It was shown to be effective and safe for patients with moderate to severe disease and was studied in combination with topical corticosteroids.

Patient Care: The updates include recommendations for new topical agents such as tapinarof and roflumilast. How do these differ from traditional topical corticosteroids or calcineurin inhibitors in efficacy, safety, and clinical use?

Stein Gold: The new guidelines incorporate two topical medications, both nonsteroidal, that received the highest level of recommendation and evidence. Tapinarof, an oral hydrocarbon receptor agonist, can be used down to age 2. I call these “one-stop shopping” drugs because they can be used anywhere on the body. The most frequent side effects are folliculitis and some dermatitis, but these were mild or moderate and generally resolved even as patients continued therapy.

These drugs simplify treatment regimens because they can be used on the face, body, and hands. With tapinarof, there is no limitation on body surface area or duration of use. Roflumilast is a topical PDE-4 inhibitor at a lower concentration than what’s approved for psoriasis. Both are once-daily drugs and can be used on any body area except mucous membranes. Roflumilast does not have the stinging and burning we have seen with other topical PDE-4 inhibitors. These are well tolerated, effective, safe options that minimize the need for topical corticosteroids.

Patient Care: In what clinical scenarios should primary care physicians consider starting or referring patients for these newer topical treatments?

Stein Gold: The newer topicals evaluated by the AAD—tapinarof and roflumilast—are really easy to use. They are not steroids, so they don’t thin the skin or lead to striae. They can be used on sensitive areas like the face, as well as on thinner or thicker plaques, and safely on larger body surface areas. These are medications that primary care physicians can incorporate into treatment for atopic dermatitis.

Patient Care: The guidelines strongly recommend lebrikizumab and nemolizumab for moderate to severe disease. How do these biologics compare to existing biologics like dupilumab in terms of effectiveness and tolerability?

Stein Gold: We now have two new biologics with the highest level of recommendation: lebrikizumab and nemolizumab. We already have dupilumab, which has been around about eight years, and tralokinumab, which targets the IL-13 receptor.

Lebrikizumab also targets IL-13 but binds at a different place, very tightly and for a long duration. It is very effective and safe. Patients start with injections every two weeks, but if they achieve treatment success, they can extend to every four weeks and maintain results. Importantly, if someone doesn’t respond well to dupilumab, they can still respond to lebrikizumab. In fact, in patients who discontinued dupilumab due to side effects, those side effects did not recur with lebrikizumab.

Nemolizumab targets IL-31, the itch cytokine. It works quickly to reduce itch and is also effective with topical corticosteroids to reduce rash. The bottom line is we now have more effective, safe options, which is critical because we have so many patients who need better disease control.

Patient Care: What should PCPs know about monitoring and managing potential adverse events with these newer biologic agents?

Stein Gold: We now have 4 biologics: dupilumab, tralokinumab, lebrikizumab, and nemolizumab. The good news is these are targeted drugs. They go directly to the aspects of the immune system involved in atopic dermatitis and are not broad immunosuppressants.

They are considered quite safe. No baseline TB testing or lab monitoring is needed. Some side effects include conjunctivitis with dupilumab, tralokinumab, and lebrikizumab—usually mild or moderate and often resolving during treatment. Nemolizumab may cause mild injection-site reactions, rare worsening of dermatitis, or mild upper respiratory infections. Overall, these drugs have strong efficacy and safety profiles.

Patient Care: How do these new recommendations fit into the broader treatment algorithm for atopic dermatitis, particularly for patients with comorbidities or higher risk of adverse outcomes?

Stein Gold: The new recommendations add lebrikizumab and nemolizumab, both FDA approved for moderate to severe atopic dermatitis. Lebrikizumab is approved only for atopic dermatitis, while nemolizumab is also approved for prurigo nodularis.

In terms of comorbidities, dupilumab is approved for asthma and other conditions, but at this point, lebrikizumab and nemolizumab have more limited indications. Even so, they add important treatment options for patients with moderate to severe disease and give us better opportunities to achieve control.