Q&A: Looking Beyond Body Surface Area in Atopic Dermatitis Treatment Selection

Dermatologists managing moderate to severe atopic dermatitis now choose among several advanced systemic therapies with strong evidence behind them. The American Academy of Dermatology (AAD)’s guidelines for adults with phototherapy and systemic therapies, published in the Journal of the American Academy of Dermatology, issued 11 recommendations.¹ Strong recommendations went to dupilumab, tralokinumab, abrocitinib, baricitinib, and upadacitinib, while systemic corticosteroids received a recommendation against use.¹

With multiple agents carrying strong recommendations, treatment selection hinges less on availability and more on matching a therapy to each patient’s goals, lifestyle, and safety priorities. Body surface area remains a common anchor for severity assessment, yet it can understate the burden of disease concentrated on the face, eyelids, head, or neck. Itch and its downstream effects add another layer. A population-based cross-sectional study of US adults, published in Annals of Allergy, Asthma & Immunology, linked atopic dermatitis to substantial itch, sleep disturbance, and impaired quality of life.²

At the 2026 Fall Clinical Dermatology Conference in Las Vegas, an Instagram Live session titled “When Atopic Dermatitis Doesn’t Follow the Script” took up this challenge, focusing on high-yield questions for busy clinics and individualized treatment algorithms.

Harrison Nguyen, MD, MBA, MPH, managing director of Harrison Dermatology Research Group and clinical assistant professor at Baylor College of Medicine and the University of Houston College of Medicine, co-led the session. In the following segment of his interview, written as a Q&A, Nguyen discusses high-impact site involvement, the weight of itch in treatment decisions, and the questions clinicians can use to uncover disease burden patients have normalized:

HCPLive: What was the impetus behind your Instagram Live session, “When Atopic Dermatitis Doesn’t Follow the Script,” and what did you discuss?

Harrison Nguyen, MD, MBA, MPH: I did that live on site with James Song. It was a lot of fun, and we really dove into the treatment landscape of atopic dermatitis. I often say we’re in the golden era of atopic dermatitis. We have a lot of really good treatment options, and our job is to find the right treatment for the right patient at the right time. So we have to ask the questions that help unlock the impact on quality of life it’s having for the patient, and be nuanced in our decision-making.

We have to choose treatments that fit into a patient’s lifestyle, but also meet the patient’s goals from an efficacy and a safety standpoint. That’s what James and I talked about: how do we ask these questions of our patients, especially in a busy dermatology clinical practice setting? High-yield questions to unlock those insights, and then how we approach it in our different treatment algorithms.

HCPLive: Were there key considerations in treatment selection you feel are worth highlighting?

Harrison Nguyen, MD, MBA, MPH: One thing to highlight is that involvement of atopic dermatitis goes beyond body surface area. For years in psoriasis, we have talked about high-impact site involvement or specialty site involvement, but that same concept really does apply to atopic dermatitis, and even beyond that. From a high-impact site standpoint in atopic dermatitis, we know, for example, 1% BSA on the face is very much different from 1% BSA on the trunk or on the arms. I have patients with just face, head, neck, or eyelid involvement and nowhere else, but that’s really impactful disease, and we have to differentiate between just BSA and the actual area of involvement for our atopic dermatitis patients.

In addition to that, something maybe we don’t talk about as much in psoriasis, but I think is even more important in atopic dermatitis, is the magnitude of itch and impact on quality of life. We find some patients may have lower BSA but have very itchy disease, and these are patients for whom we shouldn’t just key in and zero in on body surface area involvement, but really understand how the disease is impacting the patient’s quality of life, and then find the right treatment for him or her.

HCPLive: Is variation in disease impact by body site and itch emphasized enough in current guidelines?

Harrison Nguyen, MD, MBA, MPH: We talk about it. It is in the guidelines, but one of the challenges we find, especially as we teach the community and interface with other clinicians, is a practical one: finding high-yield, efficient ways to unlock those insights. Sometimes we may have a tendency to say, “How are you doing? Are you doing OK?” Patients who live with atopic dermatitis have lived with it for years.

They’re used to the itchiness. They’re used to the impact on sleep. But we have to educate our patients and tell them what is possible. It’s not a matter of just asking, “How are you doing? Are you doing fine?” “I’m doing fine” may come out verbally from a patient, but it may not signal what we really need to do for our patient. So I think the educational gap is finding ways to efficiently but effectively unlock these insights for the busy dermatologist.

Editor’s Note: This transcript has been edited for grammar and clarity using artificial intelligence tools.

References

1. Davis DMR, Drucker AM, Alikhan A, et al. Guidelines of care for the management of atopic dermatitis in adults with phototherapy and systemic therapies. J Am Acad Dermatol. 2024;90(2):e43-e56. doi:10.1016/j.jaad.2023.08.102.

2. Silverberg JI, Gelfand JM, Margolis DJ, et al. Patient burden and quality of life in atopic dermatitis in US adults: a population-based cross-sectional study. Ann Allergy Asthma Immunol. 2018;121(3):340-347. doi:10.1016/j.anai.2018.07.006.