Why Allergists Aren't Prescribing New Topical Eczema Drugs

The JTF vs. AAD Divide and Why Allergists Default to Corticosteroids

Atopic dermatitis affects an estimated 13% of children and 7% of adults in the United States, carrying a disease burden defined primarily by itch, sleep disruption, and quality-of-life impairment that substantially exceeds what its dermatologic classification might suggest to non-specialist providers.¹ The 2023 AAAAI/ACAAI Joint Task Force Practice Parameter updated topical corticosteroids and calcineurin inhibitors as the first-line standard with strong recommendations and high certainty, while issuing a conditional recommendation against topical JAK inhibitors — a position that has since been substantially revised by the 2025 AAD adult-focused update and 2026 AAD pediatric algorithm, both of which added tapinarof cream 1% (Vtama; Organon/Dermavant), ruxolitinib cream 1.5% (Opzelura; Pfizer/Incyte), and roflumilast cream (Zoryve; Arcutis) to their strong recommendation tiers.^2,3

Long-term extension data have now meaningfully enriched each of these agents’ clinical profiles: the ADORING 3 trial demonstrated a mean treatment-free interval of approximately 80 consecutive days after achieving clear skin with tapinarof, with a mean weekly Peak Pruritus NRS score of 2.9 at the end of the treatment-free interval;⁴ TRuE-AD long-term extension data showed a median of 136 to 151 days without treatment during the as-needed phase for ruxolitinib;⁵ and roflumilast’s INTEGUMENT open-label extension demonstrated that a proactive twice-weekly maintenance strategy yielded 238 to 281 days of disease control in pediatric and adult patients who achieved clearance.⁶ Despite this expanding evidence base, real-world prescribing in allergist-immunologist practices has not moved proportionately — a pattern driven primarily by limited industry education reaching allergy compared to dermatology, absence of samples in health system settings, and MOA unfamiliarity with newer agents like tapinarof whose aryl hydrocarbon receptor agonist mechanism is less familiar to allergists than the JAK or IL-4/IL-13 pathways.

Against this backdrop, HCPLive convened a group of allergist-immunologists from the New York metropolitan area for a dinner roundtable discussion on topical treatment approaches in atopic dermatitis. The forum was moderated by Autumn Burnette, MD, an allergist-immunologist at Howard University in Washington, D.C., with 12 years of faculty experience in atopic disease, and included colleagues representing private and academic allergy practices across the metropolitan area. The forum focused on the structural and educational barriers that keep allergists anchored to topical corticosteroids even as the guideline landscape has moved.

Tapinarof's Treatment-Free Interval and the Case for Proactive Topical Management

The forum surfaced a clear and consistent prescribing pattern across the panel: topical corticosteroids are the default not because panelists prefer them, but because insurance mandates step-through before newer agents, samples for tapinarof and roflumilast are largely absent in health system settings, and limited pharmaceutical education directed at allergy practices has left most panelists unfamiliar with the efficacy and safety data for the newer non-steroidals. The contrast between the 2023 JTF guidelines — which issued a conditional recommendation against topical JAKs and made no mention of tapinarof or roflumilast — and the 2025/2026 AAD updates that gave all 3 agents strong recommendations was not lost on the panel, but most panelists acknowledged they had not reviewed the 2026 AAD pediatric algorithm before this forum.

Ruxolitinib was the 1 newer non-steroidal with meaningful prescribing experience across the panel, used primarily for localized hand and eyelid dermatitis given its 15-minute itch relief onset confirmed in clinical practice. However, multiple barriers constrain broader use: the JAK inhibitor class box warning requires a disclosure conversation that several panelists described as difficult, particularly with highly educated patients; insurance prior authorization in New York specifically asks whether patients are on a biologic and blocks co-prescribing; and the 20% BSA restriction eliminates many specialist-level patients who present with more extensive involvement.

Tapinarof generated the forum’s most consequential shift in prescribing intent after the data review: “I’m wondering why I’m not using it,” one panelist said, citing the combination of no box warning, no BSA restriction, all-severity indication from mild to severe, once-daily dosing, no required lab monitoring, and compatibility with concurrent biologic therapy — a combination unavailable with ruxolitinib in the New York payer environment. As Burnette summarized the underlying pattern: “I think as an allergy community, we’re not getting as much information landing literally on our doorstep about some of the newer non-steroidals, and they’re coming at us fast.”

The ADORING 3 data review anchored the forum’s most clinically substantive discussion. The finding that approximately 80 consecutive days of treatment-free disease control follow successful skin clearance with tapinarof — with mean weekly itch scores remaining near mild at the end of the interval — was described by multiple panelists as unlike anything they had observed with any topical they had previously used.⁴ One panelist shared an anecdote of a colleague allergist with lifelong atopic dermatitis who described tapinarof as the only treatment in her experience that had ever produced a sustained period of true symptom freedom. The treatment-free interval concept resonated with the panel’s broader concern about topical therapy burden: multiple panelists described patients who space out or discontinue topicals during periods of improvement, and the prospect of clearing the skin and then having a documented, predictable off-treatment window was described as both clinically meaningful and potentially persuasive to patients exhausted by continuous topical regimens.

The discussion of roflumilast’s proactive maintenance data — twice-weekly application after clearance yielding 238 to 281 days of disease control across pediatric age groups⁶ — drew a parallel to a panelist’s existing clinical practice of prescribing tacrolimus 2 to 3 times per week in affected areas as a maintenance strategy, a pattern she described as the most effective tool in her personal management of atopic dermatitis. The panel’s consensus was that among the 3 newer non-steroidals, tapinarof had the strongest overall profile for combination use with biologics, given the absence of insurance and prescribing barriers, while ruxolitinib retained a specific niche as a fast-acting localized therapy where the 15-minute itch onset justifies the additional disclosure and prescription complexity. The forum closed with a pointed question from one panelist: “When do the insurance companies start following the guidelines?” — capturing the gap between what the 2025 and 2026 AAD updates now formally endorse and what payers still require as first-line step-through.

References

1. Silverberg JI, Hanifin JM. Adult eczema prevalence and associations with asthma and other health and demographic factors: a US population-based study. J Allergy Clin Immunol. 2013;132(5):1132–1138. doi:10.1016/j.jaci.2013.08.031

2. AAAAI/ACAAI JTF Atopic Dermatitis Guideline Panel; 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

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. Bissonnette R, Stein Gold L, Kircik L, et al. Skin clearance, duration of treatment-free interval, and safety of tapinarof cream 1% once daily: results from ADORING 3, a 48-week phase 3 open-label extension trial in adults and children down to 2 years of age with atopic dermatitis. J Am Acad Dermatol. 2025;93(3):707–714. doi:10.1016/j.jaad.2025.05.1391

5. Papp K, Bhalla B, Torres T, et al; TRuE-AD investigators. Ruxolitinib cream 1.5% for atopic dermatitis in adolescents and adults (TRuE-AD1 and TRuE-AD2): two phase 3, randomised, double-blind, vehicle-controlled trials. Lancet. 2021;397(10290):2160–2173. doi:10.1016/S0140-6736(21)00586-1

6. Davis DMR, Chovatiya R, Silverberg JI, et al. Roflumilast cream 0.15% and 0.05% in pediatric patients with atopic dermatitis: 48-week open-label extension results. J Am Acad Dermatol. 2024. doi:10.1016/j.jaad.2024.02.038 [Confirm final DOI upon indexing]