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Battle of the Two Titans: When to Progress AD Patients to Systemic Therapy


Jonathan Silverberg, MD, PhD, MPH, and Melinda Gooderham, MSc, MD, FRCPC, debated which patients are a contender for systemic therapy.

Jonathan Silverberg, MD, PhD, MPH, and Melinda Gooderham, MSc, MD, FRCPC

Jonathan Silverberg, MD, PhD, MPH, and Melinda Gooderham, MSc, MD, FRCPC

At the 2024 Revolutionizing Alopecia Areata, Vitiligo, and Eczema (RAVE) Conference in Chicago, Illinois, the crowd-favorite “Battle of the Two Titans” debate returned to discuss which patients are contenders for systemic therapies and the steps needed to make that decision. Jonathan Silverberg, MD, PhD, MPH, and Melinda Gooderham, MSc, MD, FRCPC, reviewed a patient scenario and debated throughout 3 rounds how to decide if the patient was a contender for systemic therapies and how to obtain additional information from the patient.1

Round 1: Clinical Severity

CJ is a 28-year-old female patient with atopic dermatitis. She comes into your clinic to have her pimecrolimus 1% cream prescription refilled. Do you fill the prescription and move on to the next patient, or do you stay to learn more about her atopic dermatitis symptoms?

Silverberg and Gooderham discussed how it would be beneficial to the patient to find out more about her symptoms and how fast or slow she is using the topical. In this scenario, after you decide to stay and ask more questions about CJ’s atopic dermatitis and symptoms, she shows you pictures on her phone from last week when she was having a flare on her face.

Based on these pictures, Gooderham would then want to know from CJ if she needs more pimecrolimus because she rarely uses it and only for flares, or if she uses it daily on her face and is seeing no results.

Silverberg and Gooderham asked the audience if they would classify CJ as having an AD flare and if her clinical severity warrants systemic therapy. The audience responded that more information is still needed to determine CJ’s clinical severity. According to Silverberg, when patients have atopic dermatitis lesions on their face, their clinical severity increases, in his opinion.

“The impact in terms of social functioning and everything else is a different level. And we know that a lot of times, we just may not see what's actually happening in relation to covering up with clothing or covering up with makeup,” said Silverberg.

Gooderham agreed that she would need more information to determine if this is a flare, as well as more information to determine if CJ needs a systemic therapy.

Round 2: Subjective Burden

According to Gooderham, itch is the most important subjective symptom to consider. Unlike psoriasis, where visual flaky patches are a concern, how the skin feels is a major burden for many patients with atopic dermatitis. Despite CJ showing pictures of her atopic dermatitis on her face, Gooderham would ask, “And, how is your itch?” Gooderham also noted advice that Raj Chovatiya, MD, PhD, gave to start asking every patient with atopic dermatitis about their itch until it becomes a habit. Gooderham uses that advice in her daily practice and has even added asking patients to rate their itch on a scale of 0 to 10.

Sleep is the next subjective symptom Gooderham asks about. One challenge Gooderham has faced in her practice is patients with atopic dermatitis who have become reliant on sleep aids due to itch disturbing their sleep, and therefore she isn’t always able to get a full picture of how impacted sleep in among her patients.

In the scenario of CJ, Silverberg noted that if she rated her itch as a 5 or 6 and had sleep disturbance, he would absolutely consider CJ as a candidate for systemic therapy.

“That's a systemic patient because these patients are really tough.... They've learned to cope with stuff that no human being should cope with in terms of itch and pain and bleeding all over the place,” said Silverberg.

Silverberg and Gooderham addressed the audience, who agreed that they were leaning more towards CJ being a systemic candidate, but would still like to find out more about her history of atopic dermatitis

Round 3: Lack of Treatment Response

In their final round, Silverberg and Gooderham addressed CJ’s scenario that instead of just having atopic dermatitis on her face, you find out that she also has it on her arms. For both Silverberg and Gooderham, they have had personal experiences of asking their patients with atopic dermatitis how they are doing and the patients respond that they are doing well. However, after further inspection or a full-body check, they come to find out the patient’s back or arms are covered.

In the scenario that CJ has atopic dermatitis on her face and now her body, the question arises if she has a lack of treatment response or if this is a case of non-adherence.

“This is why I would I want to know more about the pimecrolimus that she has because those are not very big tubes. When it was just on her face, whether it's plausible that she was using it frequently, but if now she has widespread disease, maybe it's not just her arms. Maybe she's showing you her arm because that's convenient, but it is also over her legs and possibly on the torso. There's just no way that she's using that to cover all of those areas,” said Gooderham.

To better address non-adherence, Gooderham asks her patients to bring their prescriptions to their appointments so that she can read the label and see when the medication was prescribed, if it’s expired, and how much product the patient has used in that time.

Regarding non-adherence, Silverberg tries to be cautious of asking patients if they missed using their treatments because he doesn’t want to seem judgmental. Instead, Silverberg frames it as, “We all miss sometimes, how often do you miss?” In his experience, Silverberg’s patients tend to give a more honest answer to that question.

“Most of us are really bad as clinicians about not trying and experiencing firsthand what we recommend to patients. You try greasing up 35% of your body with some greasy and disgusting ointment that may or may not sting or burn. When we say non-adherence, even though it's better than non-compliance as a term, that makes it seem like it’s the patient's fault. That's not the patient's fault. It's an awful treatment modality to sell to somebody for the rest of their life, and I think we have to be realistic about that,” said Silverberg.

By the end of their discussion, Silverberg and Gooderham had led the audience through all of the questions and decisions that go into deciding whether or not a patient with atopic dermatitis is a candidate for systemic therapy, including assessing itch and sleep, current treatments, and affected body surface area.

Clinical Applications

Based on their discussion, Silverberg and Gooderham highlighted Eil Lilly, the sponsor of the "Battle of the Titans," who has created a systemic therapy guide for clinicians to use when assessing a patient’s atopic dermatitis and whether to start them on a systemic agent.2

Key aspects of the guide include:

  • A vIGA-AD or IGA of 3 or 4
  • Itch ≥6
  • Sleep ≥6
  • Despite appropriate maintenance topical therapy, persistent atopic dermatitis or multiple flares over a 3-month time period
  • Patient indicates that there is an inadequate response to appropriate prescription topical therapy
  • No provider expectation of success with prescription topical therapy alone

The guide is split into 3 sections assessing the same "rounds" Silverberg and Gooderham discussed: clinical severity, subjective burden, and lack of treatment response. Systemic therapy is suggested when at least 1 criterion in each section is fulfilled, according to Eli Lilly.


  1. Silverberg J, Gooderham M. Battle of the two titans part III systemic therapy: who’s a contender. Presented at: 2024 Revolutionizing Alopecia Areata, Vitiligo, and Eczema Conference; June 8-10, 2024; Chicago, IL.
  2. Guide to advance systemic therapy in atopic dermatitis (AD). Eli Lilly. Updated May 17, 2024. Accessed June 11, 2024. https://medical.lilly.com/us/diseases/disease-education-resources/dermatology/atopic-dermatitis/answers/guide-to-advance-systemic-therapy-in-atopic-dermatitis-211747
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