The Side Effect of Doing Nothing: Reframing Atopic Dermatitis as a Systemic Disease

For some patients with atopic dermatitis (AD), the prospect of an injection or oral medication feels disproportionate to what looks, to them, like a skin problem. For those patients, overcoming their resistance to more aggressive treatment requires fundamentally reframing the disease, Adam Friedman, MD, FAAD, told Dermatology Times at the Revolutionizing Atopic Dermatitis (RAD) 2026 Conference in Nashville, Tennessee. He shared his philosophy that this is not a skin disease; it is a systemic disease that happens to manifest on the skin during his session at the conference.

Reframing Atopic Dermatitis as a Systemic Disease

Sometimes patients push back on injectables or oral medications, asking why they can’t just use a topical cream, Friedman, professor and chair of dermatology at the George Washington University School of Medicine and Health Sciences, said. In those situations, he reaches for a pointed analogy. "Would you treat diabetes with a cream? High blood pressure with a cream? These are chronic medical problems. So is this," he told Dermatology Times. "What you're seeing on the skin is the manifestation of a systemic problem, systemic inflammation."

He describes AD pathophysiology to patients as "a dysfunctional relationship between the immune system that is inappropriately reacting with a skin barrier armor that at baseline is not functioning, but that inflammation makes even worse, allowing for leaky skin, water getting out, and bad things getting in." The depth of that explanation is calibrated to each patient, Friedman noted, but the core message is consistent: AD cannot be adequately addressed with topicals alone for many patients, and treating it holistically is not optional.

The "Atopic Seizure": Why the March Model Falls Short

Friedman also challenges the conventional framing of the atopic march. Rather than a predictable linear progression, he prefers a different term altogether.

"I talk about the atopic seizure because it's not really linear," he explained. "It actually can happen at any different time point."

That unpredictability, he argued, reinforces the case for early and adequate treatment and makes waiting a harder position to defend.

The Side Effect of Doing Nothing: Flipping the Risk Conversation

Rather than waiting for patients to raise concerns about medication safety, Friedman preempts the conversation entirely. Before a patient can object to a systemic therapy, he introduces a counter-framing: what is the risk of not treating?

"What's the side effect? What's the adverse event of doing nothing?" he said. "We know untreated disease leads to badness."

He acknowledged that the likelihood of adverse events with approved therapies is generally low, but pointed to a growing body of evidence documenting the downstream consequences of undertreated AD. Reframing the risk conversation, Friedman noted, is often the way to get patients to see their condition not as a cosmetic nuisance but as a systemic disease with real medical stakes.

Medication Reconciliation and Individualizing Therapy Selection

Beyond patient communication, Friedman emphasized the imperative of treating the whole individual, which in practice means a thorough medication reconciliation before selecting an advanced therapy. For patients on multiple medications, cytochrome P450 (CYP) system interactions are a key consideration. "Many drugs do go through the CYP system," he noted, and inhibition of that pathway can result in excess drug exposure and heightened risk.

For patients on complex medication regimens, a biologic, which has no CYP-mediated interactions, may be the more straightforward choice. But Friedman was unequivocal that oral therapies, including JAK inhibitors, should not be ruled out based on comorbid disease alone. "I want to be clear that the oral medications we have should not be discarded just because someone has other comorbid diseases," he told Dermatology Times, citing data supporting JAK inhibitor use in patients with cardiovascular risk factors, including smokers.

The bottom line, Friedman said, is individualization informed by a full clinical history. "We have to treat the person, not the problem. You have to take the whole picture into account."

Additional conference coverage can be found here.