Nonsteroidal Topicals Gain Favor in Challenging AD Cases

Atopic dermatitis (AD) continues to challenge clinicians with its variability in presentation, patient impact, and therapeutic response. During a recent Dermatology Times Case-Based Roundtable in Charlotte, North Carolina, hosted by Rebecca Smith, MD, clinicians from the region shared their experiences managing real-world cases. Smith, a double board-certified general and pediatric dermatologist, led discussions focused on systemic therapy considerations, barriers to topical adherence, and the evolving role of nonsteroidal agents.

Case 1: A 31-Year-Old Man With Chronic Flares

The first case featured a 31-year-old man with a long-standing history of AD, diagnosed at 8 years old. He presented with eczematous lesions affecting approximately 10% body surface area (BSA), significant pruritus, and impaired sleep. His disease had worsened in the past year after starting a physically demanding factory job.

Topical agents that once controlled his flares were no longer effective. Panelists debated systemic vs advanced topical strategies, highlighting both practical and psychosocial barriers. One clinician pointed out the difficulty of adherence when lesions are localized to less-accessible areas: “It’s on his back, so that instantly makes it harder to treat—less likely to apply.”

Systemic escalation was considered reasonable given the BSA and impaired quality of life. However, phototherapy was deemed unrealistic due to his work schedule. Several clinicians emphasized adjunctive measures: “I would definitely give him some oral antihistamines to help a little bit with the itch…help with the sleep, since he’s not sleeping.”

The discussion underscored the importance of documenting itch and sleep disturbance when justifying systemic or biologic therapy. Ultimately, the group agreed that he was a candidate for nonsteroidal topical therapy. After weighing options, his dermatologist initiated ruxolitinib (Opzelura; Incyte) 1.5% cream twice daily, leading to rapid itch relief and skin clearance with continued use.

Case 2: A 16-Year-Old Girl With Facial Involvement

The second case involved a 16-year-old girl with AD since age 2, primarily affecting her face and neck. She had previously relied on topical therapies from her primary care provider, including corticosteroids and tacrolimus, but flares persisted. She discontinued crisaborole due to burning upon application, which is a common patient-reported barrier.

Despite years of self-management, she now sought a new treatment approach. Panelists emphasized the unique adherence challenges of adolescent patients. “Because of her age...she may use a treatment for 48 hours, and if it doesn’t work, she wants to move on,” a participant said.

Lifestyle and cosmetic factors also emerged. As one clinician observed, “She’s 16 years old, so you know she’s going to a beauty store and spending lots of money.” Products with potential irritants, frequent product switching, and social stressors contribute to poor control in this age group.

The panel discussed systemic therapy, but the patient and her family preferred another topical option before escalation. Therefore, she was started on tapinarof (Vtama; Organon) cream once daily, with the goal of improving facial control and minimizing irritation.

Case 3: A 10-Year-Old Boy With Persistent Disease

The third case focused on a 10-year-old boy with a history of AD partially controlled by topical steroids and calcineurin inhibitors. Despite these, symptoms persisted, prompting discussion of off-label and combination approaches.

One participant suggested emerging nonsteroidal options: “He needs upadacitinib, but he’s 10 [years old], so that’s tricky [because] it’s [indicated for] 12 [years] and up. So, I’d probably give him topical ruxolitinib or tapinarof.”

Others highlighted traditional compounded regimens as effective rescue options. "The Aron method, where you do the Vanicream base with betamethasone and mupirocin...has saved me, especially in littles."

The case segued into a discussion of pediatric data on topical ruxolitinib. Clinicians reviewed trial results comparing 0.75% and 1.5% formulations in children as young as 2. Although higher strengths demonstrated greater efficacy, concerns were raised about systemic absorption in younger patients. Still, enthusiasm was evident: When asked where the drug might fit if approved in younger age groups, one participant responded simply, “Everywhere, everywhere.”

Key Takeaways

The Charlotte roundtable highlighted several practical themes for dermatology clinicians:

• Severity is multidimensional. Beyond BSA, itch intensity, sleep disruption, and daily function strongly influence treatment decisions.
• Adherence remains central. Lesion location, age-specific behaviors, and lifestyle factors all shape real-world outcomes.
• Nonsteroidal topicals are shifting paradigms. Their role in both pediatric and adult patients continues to expand, particularly where long-term steroid safety is a concern.
• Systemic therapy justification requires documentation. SCOring Atopic Dermatitis, Itch Numeric Rating Scale, and quality-of-life measures provide the evidence needed for payer approval.

By weaving real-world challenges with evolving therapeutic options, this case-based exchange emphasized that individualized care—anchored in both science and patient context—remains the cornerstone of AD management.