Authors of a 2026 clinical review examine six FDA-approved targeted systemic therapies for adolescents and adults with moderate-to-severe atopic dermatitis (AD), highlighting important differences in efficacy, itch relief, safety, and treatment durability. Four biologics-dupilumab, tralokinumab, lebrikizumab, and nemolizumab-and two oral Janus kinase (JAK) inhibitors-upadacitinib and abrocitinib-offer options for patients whose disease remains inadequately controlled with optimized topical treatment. Dupilumab, approved for children as young as 6 months, has the longest established safety record and demonstrated benefits across multiple allergic conditions. The newer biologics lebrikizumab and nemolizumab, approved for AD in 2024, expand treatment choices for patients aged 12 years and older. Nemolizumab, which targets interleukin-31 signaling, can reduce itching within approximately two days, making it particularly useful for patients with itch-predominant disease. Oral JAK inhibitors also provide rapid relief, with upadacitinib improving itch as early as two days and visible skin improvement within approximately two weeks. Comparative analyses suggest that higher-dose upadacitinib may provide greater short-term skin clearance than several biologics, although safety considerations remain important.

The authors emphasize individualized treatment selection based on disease severity, predominant symptoms, age, comorbidities, prior treatment response, and patient preferences. Biologics generally offer favorable safety profiles without routine laboratory monitoring, although dupilumab and interleukin-13 inhibitors may cause ocular surface disease. Nemolizumab offers rapid itch control but may be less effective for extensive inflammation and is used with topical anti-inflammatory therapy. Oral JAK inhibitors provide broader immune pathway inhibition and rapid symptom improvement but carry FDA boxed warnings for serious infections, thrombosis, malignancy, major cardiovascular events, and death. They also require infection screening and ongoing laboratory monitoring. Treatment interruption may lead to rapid disease recurrence with JAK inhibitors, whereas some patients achieving sustained control with biologics may qualify for less frequent dosing. The authors underscore the importance of shared decision-making, balancing treatment effectiveness and safety with practical considerations such as injections, monitoring requirements, affordability, and long-term disease control.

Reference: Yousif R, Elgindi D, Paller AS. Systemic therapies for atopic dermatitis. J Am Acad Dermatol. 2026 May;94(5S):S35-S42. doi: 10.1016/j.jaad.2026.01.075.

Authors of a comprehensive review of precision medicine in atopic dermatitis (AD) highlight how differences in immune signaling, skin barrier dysfunction, and clinical presentation are reshaping treatment selection. Rather than relying solely on disease severity, emerging approaches consider individual phenotypes and molecular endotypes to identify therapies most likely to improve symptoms and long-term disease control. Targeted biologics, including dupilumab, tralokinumab, and lebrikizumab, address interleukin (IL)-4 and/or IL-13 pathways, while nemolizumab targets IL-31 signaling associated with pruritus. In the ECZTRA 3 trial, 56% of patients receiving tralokinumab plus topical corticosteroids achieved at least a 75% improvement in Eczema Area and Severity Index scores at week 16. The ARCADIA trials demonstrated significant improvements in itch as early as week 1 with nemolizumab, while oral Janus kinase (JAK) inhibitors have shown rapid clinical responses, typically within 2 to 4 weeks. Newer topical treatments, including phosphodiesterase-4 inhibitors, aryl hydrocarbon receptor agonists, and JAK inhibitors, further expand options for individualized management.

The authors emphasize a practical, phenotype-guided approach to AD treatment based on disease distribution, severity, itch predominance, skin barrier integrity, comorbidities, and previous treatment response. Patients with persistent pruritus may benefit from therapies targeting itch-related pathways, while those with involvement of sensitive areas may be candidates for steroid-sparing topical treatments. Patients with more extensive or treatment-refractory disease may require systemic biologics or JAK inhibitors, with treatment selection informed by safety considerations, particularly the boxed warnings associated with oral JAK inhibitors. Although biomarkers such as TARC/CCL17, IL-13, IL-31, and periostin show promise for predicting treatment response, none are sufficiently validated for routine endotype-guided prescribing. The authors recommend incorporating efficacy, safety, tolerability, accessibility, and remission potential into shared decision-making while emphasizing the need for prospective studies to determine whether biomarker-guided treatment improves long-term outcomes.

Reference: Fonacier L, Mawhirt S, Stern H, et al. Precision medicine in atopic dermatitis: Present and future. Ann Allergy Asthma Immunol. 2026 Sep;137(3):291-299. doi: 10.1016/j.anai.2026.06.006.

For the first time, the American Academy of Dermatology (AAD) has issued dedicated guidelines for preventing and managing atopic dermatitis (AD) in children, offering evidence-based recommendations for a condition affecting up to 25% of children worldwide. Published in April 2026, the guidelines distinguish between interventions supported by clinical evidence and commonly used prevention strategies with limited or no demonstrated benefit. Moisturizers were the only preventive intervention to receive a conditional recommendation for reducing AD occurrence in children aged 6 months to 3 years. Evidence was insufficient or showed no preventive benefit for dietary and environmental approaches, including early food introduction, human milk consumption, probiotics, vitamin D supplementation, water softeners, and dust mite avoidance. For children with established AD, the guidelines provide more than two dozen evidence-based recommendations, strongly supporting moisturizers, topical corticosteroids, topical calcineurin inhibitors, phosphodiesterase-4 inhibitors, topical Janus kinase (JAK) inhibitors, and aryl hydrocarbon receptor agonists. Biologics targeting specific inflammatory pathways and systemic JAK inhibitors also received strong recommendations for appropriate patients with moderate-to-severe disease.

The guidelines emphasize early, individualized treatment and proactive disease management to reduce flares, relieve itching, and improve quality of life for children and their families. Topical corticosteroids remain a first-line treatment for most patients because of their effectiveness, affordability, and accessibility, while nonsteroidal topical therapies offer additional options for flare control and maintenance. For more severe or widespread disease, targeted systemic therapies can provide additional benefits, with treatment selection guided by patient age, disease severity, safety, and individual needs. The AAD strongly recommends against routine systemic corticosteroid use, reserving it for exceptional circumstances involving sudden, severe flares and short-term bridging therapy. Bathing followed by moisturizing, supervised wet wrap therapy, and phototherapy received conditional recommendations, while topical antimicrobials and PUVA phototherapy are discouraged. The guidelines reinforce the importance of educating caregivers, avoiding unsupported preventive interventions, and developing treatment plans that prioritize sustained symptom control and patient well-being.

Reference: American Academy of Dermatology. American Academy of Dermatology issues first-ever pediatric atopic dermatitis guidelines, highlighting prevention strategies and effective treatments. American Academy of Dermatology. Published April 7, 2026. Accessed October 22, 2026. https://www.aad.org/news/aad-issues-first-pediatric-atopic-dermatitis-guidelines