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Atopic dermatitis and IL13 inhibitor patient candidacy
Evidence-Based Care in Atopic Dermatitis: Practical Considerations for IL-13 Inhibitors for Moderate to Severe Disease

Released: June 25, 2025

Daniel Butler
Daniel Butler, MD
Shawn G. Kwatra
Shawn G. Kwatra, MD
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In this episode, Daniel C. Butler, MD, and Shawn G. Kwatra, MD, discuss the practical considerations for using IL-13 inhibitors to treat patients with moderate to severe atopic dermatitis, including:

  • Patient candidacy considerations
  • Treatment advancement strategies that go beyond topical therapies
  • The importance of patient-centered care that address patients’ fears and needs
  • A detailed patient case to highlight take home points

Dr. Kwatra: Now we are going to talk about practical considerations for IL-13 inhibitors, which patients are good candidates and also treatment advancement strategies.

Let us start out with a case. Emma is a 17-year-old girl who has worsening AD with persistent itching and sleep disruption. She has a four-year history of atopic dermatitis, notable worsening over the past couple of years. Her symptoms are itching, scaling, nighttime scratching. She has used high potency steroids, phototherapy and emollients. Also has asthma as well.

On physical exam, very notable red, erythematous, thickened plaques, arms, legs and neck. Also with some areas of hyperpigmentation and no evidence of secondary bacterial infection. We got a good case. This is a classical case.

I think it is important now that we take a moment to discuss some of the key features that make Emma a suitable candidate for biologic therapy targeting IL-13.

Some of the big things that we know here about Emma is she is 17. She has worsening atopic dermatitis and she has itching, but she also has that sleep disruption. The sleep disruption is also a key consideration here. When I hear the word sleep disruption, I kind of perk up a little bit, especially if you are itching is bothering your sleep.

What about you, Dan? Is that one of the things that captures your attention?

Dr. Butler: 100%. It is a red flag immediately. I think it is a nice proxy way of evaluating quality of life, because a lot of times people have a hard time evaluating how much their skin disease is impacting them. They will come in, they will say, I am really uncomfortable. Then the question comes, do you want to escalate treatment? A lot of thoughts come to mind and a lot of people think, it is just my skin. Why would I take a medication? It is just my skin. I am not going to die from this, which is all true.

But then when you hear that it is impacting sleep, to me that shows us how much it is impairing your life, your ability to function. There is a lot of data behind that. When I hear that, to me it says, all right, this means we need some sort of treatment escalation.

Dr. Kwatra: Absolutely. Then when I think we heard some other key things here. The persistent itching and then the failure. We have failure of high potency topical steroids, things like clobetasol and phototherapy and also daily emollient. When you fail high potency topical steroids even throw in some phototherapy, for me that is an automatic, right? That is the key consideration.

I want you all thinking about that, that when you actually have poor control with those first-line standard therapies, that opens the door directly to these biologic treatments. I think that we still have some providers who go with a systemic immunosuppressant route, which I really think is not the right way to go now that we have very safe therapeutics. That is, again, understanding all of the different things that are affected by our treatments. And a drug like cyclosporin would affect so many different cytokines across immune axis versus IL-13 as the true biomarker of atopic dermatitis.

When you switch topical steroids, oftentimes you are really not picking up much because if you have itching, we have done some studies and others have as well showing lesions and normal appearing skin. You still have inflammation. You have inflammation in your blood. If it is not working, I do not waste a lot of time with those different topical agents.

But we are also going to talk a little bit more about the practical nitty-gritty of getting your patients on biologic therapy. When to advance therapy? Persistent symptoms despite optimized topical therapy. Having that in your notes documented very important for getting these therapeutic agents approved. That is really the most important thing.

Also having flare ups with itch and sleep disturbances. Sometimes we monitor that with some tools like the itch numeric rating scale score zero to 10. What is your worst itch in the last 24 hours? You get a quick sense of where people line up. There is also some tools for the eczema severity, the EASI score, the SCORAD, and then advancing systemic therapies. The biologics are very tailored, very specific treatment options.

You do have other options, systemic nonspecific therapies. There are also JAK inhibitors which are also pretty fast in terms of their efficacy.

Having these patient-centered conversations about fears and expectations of biologics are very important. Actually, talking about how this is much more specific therapy targeting one thing, one molecule, that is the number one biomarker in atopic dermatitis.

Then talking more about the long-term benefits. Excellent great safety data and shared decision-making, also some of the trade-offs of not treating, appropriately and having continued disease, some of those trade-offs of what that actually means.

But it is really important that we actually hear from a live patient about their experience. We can talk about it all the time, but it is great to hear it directly from a patient. So we are going to share that story for you now.

Chava Wald: When the option for trying biologic treatment was first proposed to me, at first I was terrified that at the idea of being jabbed by a needle, not just one, but two and pretty frequently really scared me. Next was the cost of financial burden that would impose on me, being that the drug is fairly new and quite expensive and there would be certain financial implications on that.

Lastly, the practical part of who is going to administer and how it would be administered, whether I am at home or on the road was a challenge, but that was much lower down on the level of considerations into starting a biologic.

When considering a new treatment, and this really applies for all treatments, not just the biologic. For me personally, the number one consideration is how safe it is. What are the side effects? Subsequently cost, because a lot of these medications are very pricey.

Convenience, again is a last consideration, because if the medication is working and it is helping and it is improving my day to day quality of life, then the potential slight inconvenience that it might play a role into my day to day living, for example, traveling with a biologic only happens seldomly, so I would not prevent that from being a reason to attempt a new treatment, specifically a biologic.

Dr. Kwatra: That is great. Let us touch on some of our key takeaways. IL-13 drives atopic dermatitis pathology, impairs the skin barrier. IL-13 leads to decreased filaggrin and loricrin, increases inflammation and itch. Biologic therapies that target IL-13, improve barrier function, reduce inflammation, and also decrease pruritus.

We know that failing the first-line topical therapies, high potency topical therapy is one of the main things that allows you to then go to that next step. Also, the important patient factors of frequent flares of their itch are very important.

When you are on these advanced therapies, you can easily monitor with some simple tools like an itch numeric rating scale tool, or the EASI score. Then it is very important to also have patient-centered biologic discussion. Talking about safety concerns like conjunctivitis, injection reactions and emphasizing also the long-term disease control and reduce steroid use and some of the different problems that we have with steroids. Although many primary care providers oftentimes give these steroids, they are definitely associated with all sorts of side effects that patients need to be aware of.

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