Deciding Which Patients With Atopic Dermatitis to Prioritize for Biologics and Janus Kinase Inhibitors

Abstract

Atopic dermatitis (AD) is a common, chronic inflammatory skin disorder associated with reduced quality of life related to itch, sleep disturbance, risk of cutaneous infections, mental health issues, and high caregiver stress. Biologics and Janus kinase (JAK) inhibitors are transformative treatments for moderate-to-severe AD, providing options for patients' unresponsive to conventional topical therapies. Dupilumab, tralokinumab, lebrikizumab, and nemolizumab are injectable biologics that offer durable control by targeting the underlying skewing to type 2 inflammation. Dupilumab, the first available biologic, is approved for patients as ≥6 months old and concurrently manages atopic comorbidities, particularly allergic asthma. In contrast, JAK inhibitors-upadacitinib, abrocitinib, and baricitinib-are oral therapies, offering rapid relief of inflammation and pruritus by inhibiting the JAK-STAT (signal transducer and activator of transcription) pathway, which is downstream of type 2 immune receptors. JAK inhibitors are approved for ≥12 years old in the United States, but in other geographic regions for those ≥2 years of age (baricitinib). This review highlights key considerations for selecting among these advanced therapies, including age, comorbidities, efficacy, and safety profiles. By integrating the latest evidence, this article provides a practical guide for clinicians to tailor treatment approaches and improve outcomes for individuals with AD.

Keywords: Abrocitinib; Atopic dermatitis; Baricitinib; Biologics; Dupilumab; Janus kinase; Janus kinase inhibitor; Lebrikizumab; Nemolizumab; Tralokinumab; Upadacitinib.