Managing Adverse Events and Monitoring in Advanced Atopic Dermatitis Systemic Therapies

Conclusions

• Biologic and JAK-inhibitor adverse events in atopic dermatitis are usually manageable without extensive routine monitoring, especially for biologics.
• Conjunctivitis is the most common biologic-related ocular issue, particularly with IL-13–pathway agents, and is more likely in patients with severe disease or baseline periocular/ocular involvement.
• New or persistent facial redness on biologics is often not a true drug toxicity and may reflect residual dermatitis, contact dermatitis, irritant dermatitis, or topical steroid withdrawal.
• Most patients with atopic dermatitis and facial involvement improve on dupilumab or other IL-4/IL-13 pathway blockers, but complete facial clearance is difficult and may require adjunctive topical or diagnostic strategies.
• Inflammatory arthralgias can occur with dupilumab and sometimes tralokinumab, and switching from IL-4 blockade to IL-13–only therapy may help some patients.
• Psoriasiform or other new rashes can appear on both biologics and JAK inhibitors, but the most important atypical eruption to rule out is cutaneous T-cell lymphoma.
• The overall evidence does not show a clear causal increase in CTCL from dupilumab after accounting for disease severity, but severe atopic dermatitis itself is a major CTCL risk factor and atypical or persistent eruptions should still be biopsied.
• Nemolizumab appears to have a generally acceptable safety profile, but eczema flares, asthma exacerbations, edema, and other inflammatory skin reactions remain possible.
• For JAK inhibitors, the main practical safety issues are zoster risk and age- and comorbidity-related caution rather than absolute contraindications.
• Vaccination against zoster and pneumococcus should be considered when feasible before or during JAK-inhibitor therapy.
• Long-term safety data for abrocitinib and upadacitinib are broadly reassuring, with serious infections, thrombosis, MACE, and malignancy remaining uncommon.
• Older age, especially over 65, is associated with higher adverse-event risk on JAK inhibitors, so treatment should be individualized with shared decision-making.
• Cyclosporine and methotrexate remain useful, cost-effective options when used carefully with appropriate safety monitoring.
• Across therapies, clinicians should stay flexible, adjust dose or switch agents when adverse events occur, and let patient preferences guide treatment decisions.