Recognizing Atopic Dermatitis as a Systemic Disease to Prevent Undertreatment

In a continuing conversation at the Revolutionizing Atopic Dermatitis (RAD) 2026 meeting, Mona Shahriari, MD, FAAD, discussed evolving perspectives in atopic dermatitis (AD) management, including the need to recognize AD as a systemic disease, personalize treatment selection, and optimize the use of topical and systemic therapies.

A key challenge in AD care, according to Shahriari, is the ongoing debate about whether the disease should be viewed solely as a skin condition or as a systemic inflammatory disorder. Unlike psoriasis, where systemic manifestations and comorbidities are widely recognized, the broader impact of AD has not been as clearly defined. However, emerging data suggest that moderate-to-severe AD may affect multiple aspects of health, including cardiovascular risk, childhood growth, pregnancy outcomes, and fertility.

Shahriari emphasized that recognizing AD’s systemic nature is critical to preventing undertreatment. In clinical practice, she considers systemic therapy earlier for appropriate patients, particularly when disease burden extends beyond what is visible on the skin. She noted that treatment decisions should be individualized based on factors such as patient preferences, comorbid conditions, and lifestyle considerations.

“The biggest challenge is if the world doesn't recognize AD as a systemic disease, we're going to continue to have under treatment,” she said.

The expanding AD treatment landscape has made shared decision-making increasingly important. Shahriari explained that selecting a therapy involves understanding each patient’s priorities, including whether they prefer oral medications or injectable therapies, as well as identifying comorbidities that may influence treatment choice. Conditions such as asthma, eosinophilic esophagitis, and conjunctivitis may help guide therapy selection.

She also highlighted the importance of addressing patient concerns and misconceptions about advanced therapies. Rather than assuming why a patient may hesitate to start a medication, Shahriari recommends asking what specifically worries them and providing education tailored to those concerns. She shared an example of a pediatric patient whose parent initially expressed concerns about dupilumab but became comfortable with treatment after discussing benefits, risks, and expectations.

While systemic therapies have transformed AD care, Shahriari stressed that topical treatments remain an essential part of management. She views topical therapies as an adjunct throughout the treatment journey, including for patients receiving systemic therapy who may experience breakthrough disease.

However, she noted that newer topical therapies may contribute to delays in systemic treatment for some patients because clinicians still lack standardized definitions of topical treatment failure. Shahriari suggested evaluating failure based on three categories: lack of efficacy, intolerance or adverse effects, and feasibility challenges related to treatment burden.

Finally, Shahriari underscored the importance of ongoing communication and realistic expectations. She recommends early follow-up, often at four weeks, to assess response, address barriers, and reinforce adherence. By maintaining open dialogue and recognizing the challenges patients face living with AD, clinicians can better support long-term treatment success.

“We're kind of like detectives in dermatology, where you get that spidey sense that tells you, ‘Okay, something is off,’” she said. “Then I start to look for other reasons why their skin is not responding, and sometimes adherence becomes the main reason.”