Q&A: Which Factors Guide the Choice Between JAKi, Biologics, or Other AD Drugs?

The therapeutic landscape for atopic dermatitis has evolved in recent years, providing clinicians in the field with an expanding range of topical, biologic, and oral treatment options.

While these advances have created new opportunities to improve patient outcomes, they have also introduced greater complexity into the selection of drugs, requiring dermatologists to weigh disease severity, comorbidities, patient preferences, and quality-of-life considerations when determining the most appropriate medication.

In this Q&A interview with HCPLive, conducted on-site at the Revolutionizing Atopic Dermatitis (RAD) Conference in Nashville, Harrison Nguyen, MD, MBA, MPH, founder of Harrison Dermatology & Research Group, speaks on the key themes from his session, ‘Medical Crossfire.'^1,2 He shared his views on tailoring treatment decisions to individual patients, identifying when to escalate from topical to systemic therapy, and the importance of shared decision-making:

HCPLive: You gave a talk at RAD titled ‘The Medical Crossfire.’ In light of this session, what are some of the most common areas of debate when choosing between topical therapies, oral agents, and biologics for atopic dermatitis?

Nguyen: Well, I often say we're in a golden revolution of atopic dermatitis. We have, fortunately, several options for treating our patients, both from a topical standpoint and also systemic. As we're understanding more and more about these therapies, both ones that are established and emerging, we're trying to understand which patient will benefit from which therapy. For each therapy, we're understanding more and more about their biologic behavior, how they behave in certain manifestations of atopic dermatitis, and, of course, which patient would benefit the most based on those characteristics.

So, I presented a case of a teenage patient with atopic dermatitis with a significant history of atopic disease in that patient's family. The mom has a history of asthma. Dad has a history of food allergies and allergic rhinitis. Actually, a younger sibling has developed new-onset chronic spontaneous urticaria. All type 2 inflammatory diseases. In my presentation, I argued that the best treatment for this patient, once we made the decision to escalate from a topical treatment to a systemic treatment, is dupilumab. Why is that? Dupilumab blocks not just IL-13 but IL-4 as well. IL-4 is critical in so many mechanisms of type 2 inflammation.

It's critical in class switching for antibodies is critical. Critical in Th2-mediated disease. So if we can interfere and block IL4 in addition to IL13, our patients will really benefit from it. Not only are we able to control their symptoms of atopic dermatitis, but we're also seeing emerging data that we're able to prevent the development of other type two inflammatory diseases, things like asthma, things like allergic rhinitis. Then also [we may be] able to address other comorbidities that may emerge, such as chronic spontaneous urticaria.

HCPLive: When you're evaluating a patient with moderate to severe disease, what factors most strongly impact your decision to then escalate from topicals to a systemic?

Nguyen: It's quality of life. The impact on quality of life is the single most important driver of escalation of therapy. It's the impact on the itch. So, is a patient so itchy that it's interfering with his or her ability to sleep, his or her ability to function, his or her ability to work or to study? Is the topical burden so overwhelming that it’s also interfering with quality of life? Sometimes for parents who are caregivers for patients or adolescents with atopic dermatitis, the burden of having to apply topicals can be really challenging for caregivers.

We really want to understand the patient's journey, the patient's impact on quality of life, and then from there, we also go into things like preferences, comorbidities, and of course, manifestations of disease. We stratify based on specialty site involvement, such as head and neck atopic dermatitis, atopic dermatitis affecting the hands and the feet, because these types of involvement in specific areas will also determine our selection as well.

HCPLive: There's a growing number of available therapies. How has your approach to treatment sequencing evolved? Are there situations where you're moving quickly towards oral or biological therapies that maybe more quickly than you would have several years ago?

Nguyen: I believe that we should always meet the patient where they are. So it doesn't matter if they walk into my clinic for the first time and they've never tried a topical treatment, but they're covered from head to toe with atopic dermatitis…I'm not going to delay treatment and say, ‘Okay, we're going to try topicals first.’ We know that a patient is a systemic or biologic patient, right? So I try to meet the patient where they are in their atopic dermatitis journey. You know, for some patients, we do start with topicals, but when the burden of disease is impactful, no matter what time they're meeting me, I try to meet them where they are.

Typically, in my practice, I will usually start with a biologic. We have four biologics available: dupilumab, lebrikizumab, tralokinimab, and nemolizumab. But we also have 2 systemic JAK inhibitors: abrocitinib and upadacitinib. And for my patients who I think will benefit from the get-go from JAK inhibition right away, I have no hesitation to put them on a JAK inhibitor and not step through a biologic. But that being said, the majority of the time I do start with a biologic. It's not necessarily escalating faster. It's just meeting the patient where they are.

HCPLive: For clinicians who are attending this session, what practical takeaways do you hope they take away regarding how to individualize treatment selection and engage patients in shared decision-making?

Nguyen: I hope the audience took away key principles about understanding each atopic dermatitis patient's presentation preferences and journey. Not every atopic dermatitis patient is the same, and we want to choose the best treatment for the patient in front of us. Take into account the patient's presentation. What anatomical sites are affected, the patient's comorbidities, and patient preferences, so that we can really cater our treatment to our patient. Sometimes, I think it feels like we have good treatment for atopic dermatitis, and we can just do 1 treatment for every patient in front of us. We would probably get good results, ranging from good to excellent for all our patients, or at least for the vast majority of them. But I think if we take a customized, catered approach, we can get excellent results for each and every 1 of our patients based on their characteristics, disease course, and their patient preferences.

Editor’s note: Nguyen had no relevant financial disclosures of note.

References

1. Nguyen H, Bunick C, Cotter D, Shahriari M. Medical Crossfire and Clinical Case Challenge. Session presented at: 2026 Revolutionizing Atopic Dermatitis Conference; June 17-19, 2026; Nashville, TN.

2. Nguyen H. Emerging Evidence in Atopic Dermatitis Management, With Harrison Nguyen, MD, MBA, MPH. HCPLive. June 19, 2026. Accessed July 29, 2026. https://www.hcplive.com/view/emerging-evidence-atopic-dermatitis-management-harrison-nguyen-md-mba-mph.