Special Report: Treat-to-Target in Atopic Dermatitis—Applying the AHEAD Recommendations

The systemic treatment landscape for moderate to severe atopic dermatitis has shifted from broad immunosuppression to targeted therapies supporting both short-term control and long-term disease modification.

In this video, host Mona Shahriari, MD, contrasts historical reliance on nonselective immunosuppressants, which often had challenging safety profiles, with current options that include biologics and JAK inhibitors offering higher efficacy thresholds and more favorable long-term safety. She frames the central clinical question as, “What is the end game?” and introduces the AHEAD treat-to-target recommendations as a framework for defining what “good” long-term control should look like, beyond simply being “better than baseline.”

In this video, part of a 6-part Special Report series on switching therapeutic classes in atopic dermatitis, Shahriari explains that AHEAD is a global consensus initiative encompassing approximately 100 clinicians from 44 countries, designed to raise the standard of atopic dermatitis care worldwide. The recommendations set ambitious targets within 3 to 6 months of therapy initiation, emphasizing high levels of both clinician-reported and patient-reported outcomes. Targets include EASI 90, IGA 0/1, and low body surface area (BSA) involvement on the clinician side, and nearly complete resolution of itch on patient-reported scales. Expert guest Andrew Mastro, MS, PA-C, highlights how these treat-to-target thresholds align clinical expectations with patient goals and embed shared decision-making into routine care rather than treating it as an optional add-on.

Mastro then discusses practical implementation using both traditional measures (IGA, BSA, itch numeric rating scale) and the Atopic Dermatitis Control Tool (ADCT). He notes that ADCT can be embedded in electronic medical records and administered by support staff or via tablets before the visit, providing a six-item, 30-second assessment of symptoms, sleep, mood, and overall bother. Shahriari echoes her preference for ADCT and adds that she often supplements objective metrics with a direct question about whether patients are satisfied with their current level of control or wish it were better. This simple phrasing can uncover residual disease burden in individuals who may fear losing partial gains if therapy is changed.

Relevant disclosures for Shahriari include AbbVie, Apogee, Arcutis, Bristol Myers Squibb, Dermavant, Galderma, Incyte, Johnson & Johnson, LEO, Lilly USA, Novartis, Regeneron, Sanofi-Genzyme, Takeda, UCB, Pfizer, and others. Mastro has no relevant disclosures to report.

References:

Silverberg JI, Gooderham M, Katoh N, et al. Combining treat-to-target principles and shared decision-making: International expert consensus-based recommendations with a novel concept for minimal disease activity criteria in atopic dermatitis. J Eur Acad Dermatol Venereol. 2024;38(11):2139-2148. doi: 10.1111/jdv.20229

Silverberg JI, Bunick CG, Hong HC, et al. Efficacy and safety of upadacitinib versus dupilumab in adults and adolescents with moderate-to-severe atopic dermatitis: week 16 results of an open-label randomized efficacy assessor-blinded head-to-head phase IIIb/IV study (Level Up). Br J Dermatol. 2024;192(1):36-45. doi: 10.1093/bjd/ljae404