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Presentation

Atopic Dermatitis Itch-Dominant Phenotypes, Assessment, and Treatment Advances

Description

The speaker emphasized that itch is the central burden in atopic dermatitis and often persists for years, with many patients experiencing daily, severe, and sometimes painful or burning sensations that also disrupt sleep and mental health. He argued that clinicians often over-focus on visible skin lesions and under-ask about symptoms, leading to missed recognition of an itch-dominant phenotype in which patients may have only mild-to-moderate lesions but severe itch, poor control, frequent flares, and delayed escalation to systemic therapy. He recommended documenting itch at every visit, using patient-reported outcomes alongside clinician assessment, and setting long-term treat-to-target goals that include symptom relief, not just lesion improvement. He also noted that itch quality descriptors such as burning, stinging, and crawling may signal more refractory disease and are common in areas like the face, hands, and eyelids. In treatment, topicals have limited evidence for itch control in many patients, while systemic therapies and biologics—especially JAK inhibitors and now nemolizumab—show stronger and faster itch relief, though even the best therapies do not eliminate itch in all patients. Overall, the talk called for better phenotyping, more attentive listening, and more symptom-centered management of atopic dermatitis.

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Conclusions

Itch is a central and highly burdensome symptom of atopic dermatitis, often involving severe, long-lasting, and sleep-disrupting distress.
Itch in atopic dermatitis is frequently unstable over time, so long-term treatment planning and maintenance strategies are necessary.
Clinical severity based on skin lesions often does not match the patient’s itch experience, creating a major clinician-patient disconnect.
An itch-dominant subtype of atopic dermatitis exists and is common enough to matter clinically, but it is often missed if clinicians rely only on visual skin assessment.
Patients with itch-dominant disease tend to have worse quality of life, poorer disease control, more flares, and greater need for systemic therapy.
Regularly asking and documenting itch severity at every visit is essential for proper assessment and management.
Patients’ descriptions of itch as burning, stinging, pain-like, or crawling may signal more severe and refractory disease.
Topical therapies can help some patients, but they often fail to adequately control itch when disease is widespread or symptom-dominant.
Among current systemic options, JAK inhibitors appear to provide the fastest and strongest itch relief, especially early in treatment.
Biologics such as dupilumab and lebrikizumab improve itch, but generally more slowly than JAK inhibitors.
Nemolizumab appears to be a valuable new option for itch, with very rapid and durable antipruritic effects.
Treatment goals in atopic dermatitis should combine clinician-rated skin improvement with patient-reported symptom control, especially itch and sleep.
Even with the best available therapies, complete itch freedom remains difficult to achieve for many patients, indicating ongoing unmet need.

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