Examining Topical Therapy for Atopic Dermatitis: Clinical Forum Perspectives

Topical corticosteroids and calcineurin inhibitors remain foundational in atopic dermatitis, but 3 newer nonsteroidal topicals, ruxolitinib, tapinarof, and roflumilast, are now approved down to 2 years of age. Recommendations for these agents differ by specialty, with the 2023 Joint Task Force (JTF) guideline from the allergy societies conditionally recommending against topical Janus kinase (JAK) inhibitors, while American Academy of Dermatology recommendations reviewed at the forum support all 3 agents.^¹⁻⁴ Allergists, who often see children whose families suspect a food or environmental trigger, are weighing where these therapies fit alongside traditional options.

In October 2026, Gregory Bensch, MD, an allergist-immunologist at Allergy, Immunology and Asthma Medical Group in Stockton, California, moderated a clinical forum in San Francisco with allergy and immunology clinicians from the Bay Area and Northern California. The discussion covered quality-of-life burden, barriers to treatment, topical treatment sequencing, and efficacy and safety data for the newer nonsteroidal agents.

Atopic Dermatitis Burden and Barriers to Topical Therapy

Participants said most patients with atopic dermatitis they see are children, often brought in by parents seeking an allergic cause, and several said long waits for dermatology appointments push adults toward allergy practices. Itch, pain, and sleep loss for both patients and caregivers were cited as the most burdensome symptoms, along with appearance concerns among adolescents. Several participants said antihistamines do little for atopic dermatitis-related itch beyond sedation.

Participants cited adherence, fear of topical corticosteroids, and concern that nonsteroidal therapies are "immunosuppressive" as common barriers. They said boxed warnings still prompt questions, though less often for calcineurin inhibitors given more than 20 years of experience, and payer requirements were described as the leading obstacle to newer agents. Several said they consult dermatology mainly for uncertain diagnoses, suspected infection, or biopsy.

Topical Treatment Sequencing in Atopic Dermatitis

For infants, participants described starting with low-potency corticosteroids such as desonide ointment or fluocinolone oil, and several said they still use tacrolimus ointment because coverage is easier to obtain. Most said they rarely escalate to high-potency corticosteroids and instead move to a newer nonsteroidal topical once mid-potency corticosteroids fail, with 1 participant arguing that topical corticosteroid efficacy plateaus at medium potency while adverse effects increase. Many described proactive maintenance applications 2 to 3 times weekly on recurrent sites.

Participants said tolerability influences their choice, describing burning with crisaborole but little stinging with the newer agents, including on the face and eyelids. In 1 participant's practice, patients test samples of several nonsteroidal creams on their skin during the visit and choose the most comfortable option. Participants said high body surface area, failure of multiple topicals, involvement of the hands or face, and comorbid type 2 conditions push them toward systemic therapy.

Ruxolitinib, Tapinarof, and Roflumilast in Practice

For ruxolitinib cream, participants reviewed TRuE-AD data showing treatment success in more than half of patients at week 8 and itch reduction within 15 minutes of application.^² Several cited the rapid itch relief as a key benefit, while others noted the JAK inhibitor class boxed warning. Participants said maximal-use pharmacokinetic data were reassuring, though 1 cautioned that absorption may be greater in patients with severe, widespread disease.

For tapinarof cream, participants reviewed ADORING data in moderate to severe atopic dermatitis, including a mean of nearly 80 consecutive treatment-free days in the long-term extension.^³ Participants said it works well and is well tolerated, and none reported folliculitis, the most common adverse event in trials. Several valued its once-daily, nongreasy formulation for children with sensory issues, while 1 participant described the long treatment-free intervals as unexplained and worth further study.

For roflumilast cream, participants said efficacy was solid in the INTEGUMENT trials and improved in the open-label extension, though perhaps less rapid than with the other 2 agents.^⁴ They also noted low application-site irritation and the option of twice-weekly maintenance dosing once skin clears. Participants said once-daily dosing with tapinarof and roflumilast is an advantage, since patients prescribed twice-daily therapy often apply it once.

Participants said they typically follow up within 4 to 6 weeks of starting therapy, and 1 suggested distinguishing acute from maintenance treatment, as in asthma. "And I think as we start to understand the neuroimmunology, we will get better at controlling the pain and itching these patients really suffer from," Bensch said.

References

1. Chu DK, Schneider L, Asiniwasis RN, et al. Atopic dermatitis (eczema) guidelines: 2023 American Academy of Allergy, Asthma and Immunology/American College of Allergy, Asthma and Immunology Joint Task Force on Practice Parameters GRADE- and Institute of Medicine-based recommendations. Ann Allergy Asthma Immunol. 2024;132(3):274-312. doi:10.1016/j.anai.2023.11.009

2. Papp K, Szepietowski JC, Kircik L, et al. Efficacy and safety of ruxolitinib cream for the treatment of atopic dermatitis: results from 2 phase 3, randomized, double-blind studies. J Am Acad Dermatol. 2021;85(4):863-872. doi:10.1016/j.jaad.2021.04.085

3. Silverberg JI, Eichenfield LF, Hebert AA, et al. Tapinarof cream 1% once daily: significant efficacy in the treatment of moderate to severe atopic dermatitis in adults and children down to 2 years of age in the pivotal phase 3 ADORING trials. J Am Acad Dermatol. 2024;91(3):457-465. doi:10.1016/j.jaad.2024.05.023

4. Simpson EL, Eichenfield LF, Alonso-Llamazares J, et al. Roflumilast cream, 0.15%, for atopic dermatitis in adults and children: INTEGUMENT-1 and INTEGUMENT-2 randomized clinical trials. JAMA Dermatol. 2024;160(11):1161-1170. doi:10.1001/jamadermatol.2024.3121