Italian Experts Reach Consensus on Defining and Managing Moderate Atopic Dermatitis

Atopic dermatitis has long been described in three tidy tiers — mild, moderate and severe — but the middle tier has never enjoyed the clinical clarity of the other two. A new consensus study from Italy argues that this ambiguity has real consequences: patients with moderate disease are frequently caught between topical treatments that may not be enough and systemic therapies that guidelines and reimbursement rules often reserve for severe cases. The study, published in Dermatology and Therapy, used a structured expert agreement process to define what moderate atopic dermatitis actually is, how much it burdens patients, and where its management falls short.

The research team, led by Antonio Costanzo and colleagues on behalf of the AD Delphi Working group, employed a multi-round Delphi methodology, a technique designed to harmonize expert opinion across a complex field. A board of 11 dermatologists with expertise in atopic dermatitis first reviewed the available literature, identified through a PRISMA-guided search of PubMed/Medline restricted to a ten-year reference period, full-text English-language articles and adult human subjects. From that desk analysis the board generated 31 survey statements grouped into four domains: diagnosis and classification criteria, the burden of moderate disease, treatment, and unmet needs.

Those statements were then put to a wider voting panel. In total, 69 dermatologists representing diverse geographic areas across Italy were invited to participate, and 48 accepted. Panel members rated each statement on a five-point Likert scale, and consensus was defined as at least 75 percent of panelists scoring a statement four or five, corresponding to agree or strongly agree. In the first round, every one of the 31 statements reached consensus, with three achieving unanimous agreement, twenty reaching 90 to 99 percent, and eight falling between 80 and 89 percent. After the panel’s comments were reviewed, the statements were revised and condensed to 26 and voted on again in a second round, in which 36 of the original panelists took part. Unanimous consensus grew from three statements to ten, fourteen statements reached 90 to 99 percent agreement, and only two fell in the 80 to 89 percent range.

The most concrete output of the process is a set of agreed thresholds for defining moderate disease. The panel unanimously endorsed classifying moderate atopic dermatitis by an Eczema Area and Severity Index (EASI) score ranging from 7.1 to 21.0. EASI is a validated, standardized composite that integrates body surface area with the intensity of four clinical signs — erythema, induration or papulation, excoriation and lichenification — into a single numerical score. Because it does not capture symptoms, the experts also unanimously supported supplementing it with validated patient-reported outcome measures. These include the Patient-Oriented Eczema Measure (POEM), which tracks the frequency of seven signs and symptoms over the previous week, and the Dermatology Life Quality Index (DLQI), which measures the impact of skin disease on quality of life. In a population-based cohort of adults, severity strata indicated a DLQI range of 6 to 10 and a POEM range of 8 to 16 for moderate disease. The Patient-Oriented Scoring Atopic Dermatitis tool, which assesses lesion extent and severity alongside pruritus and sleep disturbance, corresponds to a score of 25 to 50 in moderate disease. The Hospital Anxiety and Depression Scale can additionally evaluate mental health; in one study, adults with moderate atopic dermatitis had significantly higher mean scores for anxiety and depression than control subjects. Because no single instrument captures every dimension of the disease, the panel recommended combining multiple tools for accurate diagnosis and severity stratification.

The experts also agreed that exacerbations should be evaluated considering both clinical signs and the patient’s own perspective. Flares are a highly individualized experience, and patients may be in the best position to determine whether they are experiencing one. This emphasis on the patient’s voice runs through the entire consensus: the decision-making process about treatment frequently prioritizes objective clinical findings and investigator-derived assessments while overlooking patient-reported outcomes such as pruritus intensity, sleep disturbance, fatigue and psychological distress.

Every statement in the burden-of-disease domain received 100 percent agreement, underscoring the panel’s view that a significant impact on quality of life is not limited to severe disease. The panelists confirmed the pivotal role of pruritus, which in moderate disease has been associated with a Numeric Rating Scale score of at least 4 out of 10. Relentless, chronic itch is a hallmark symptom of atopic dermatitis and a primary driver of its burden, impairing sleep quality and contributing to social isolation, anxiety and reduced quality of life. The panel also highlighted mental health issues including anxiety, depression and social avoidance behaviors, as well as patient dissatisfaction with prolonged topical treatment with corticosteroids and calcineurin inhibitors, whether due to lack of efficacy or side effects. Large-scale patient surveys have revealed that the multidimensional burden of the disease is strongly associated with the time spent managing symptoms, suggesting a need for more effective therapies that improve symptoms and reduce that management burden. Consensus data on burden were consistent with recent results from the European National Health and Wellness Survey, which found that the most common comorbidities in moderate disease overlap with those experienced by patients with severe disease. One study of Australian adults further showed that moderate disease appears to have a greater effect on psychological wellbeing, whereas severe disease has a greater impact on physical health.

On treatment, the consensus describes moderate atopic dermatitis as occupying a clinical limbo. Mild cases are managed with topicals and severe cases with systemic therapy as the clear standard, but moderate disease is often underestimated and inadequately treated, requiring approaches that sometimes necessitate more potent therapies to achieve adequate control. European guidelines recommend a stepped-care plan beginning with emollients and moisturizers combined with patient education, then topical anti-inflammatory agents such as corticosteroids and calcineurin inhibitors alongside psychological counseling and phototherapy, and finally, for moderate-to-severe disease failing conventional first-line systemic therapies such as short courses of corticosteroids, methotrexate, cyclosporine or azathioprine, advanced therapies including biologics and Janus kinase inhibitors. The statements on treatment achieved agreement ranging from 89.6 to 100 percent.

The consensus’s sharpest criticism is reserved for the regulatory environment. In Italy, as in several other countries, reimbursement for innovative therapies is governed by stringent administrative thresholds rather than clinical needs alone. Advanced therapies, including the biologics dupilumab, tralokinumab, lebrikizumab and nemolizumab, and the Janus kinase inhibitors upadacitinib, abrocitinib and baricitinib, are not eligible for reimbursement for moderate disease alone. Being excluded from innovative care, patients with moderate disease are often forced into an inadequate therapeutic cycle, choosing between insufficiently effective topical regimens and traditional systemic immunosuppressants that are often poorly tolerated or associated with a significant risk of cumulative adverse events. The authors argue that although innovative therapies are associated with higher upfront expenditures, they are expected to confer long-term economic advantages by mitigating direct medical costs related to disease progression, treatment-related adverse events and the need for intensive follow-up, as well as indirect costs arising from impaired quality of life and productivity loss. The development of novel topical agents is also a rapidly advancing field that could help optimize management for patients who do not yet meet severity thresholds for systemic therapy.

The unmet-needs domain, with statements achieving agreement of at least 89.6 percent, identified timely access to innovative and effective therapies, effective itch control and skin lesion management, sleep quality improvement, long-term disease control with flare prevention, long-term therapy safety, access to psychological support, and enhanced patient-physician communication to improve adherence as key gaps. The authors note that it has been hypothesized that pruritus, psychological stress, social isolation, depression and anxiety combine into a vicious cycle in patients with the disease. They also stress that the findings on reimbursement are applicable only to the Italian healthcare and reimbursement context and should not be extrapolated to other national settings, since treatment adjustments are limited by strict criteria set by the Italian Medicines Agency even when moderate symptoms, particularly pruritus, are inadequately controlled by conventional therapies.

The authors acknowledge important limitations. This national Delphi consensus is constrained by potential expert selection bias, its findings may have limited external validity beyond the national context, and the results depend inherently on the composition of the expert panel. The consensus was developed and voted exclusively by dermatologists, and future iterations should incorporate patient representatives to ensure the statements reflect patients’ lived experience and priorities. The iterative process may also have attenuated dissenting views, and a Delphi consensus cannot substitute for evidence derived from prospective or real-world clinical outcomes. With those caveats in place, the authors present this as the first multi-round Delphi study focusing specifically on moderate atopic dermatitis, describing it as a basis to reshape and optimize the allocation of healthcare and financial resources so that patients whose disease is clinically significant but administratively invisible are no longer left without access to safer, more targeted options.

Subject of Research: An Italian Delphi consensus on the classification, burden and management of moderate atopic dermatitis

Article Title: Current Challenges in Atopic Dermatitis: An Italian Delphi Consensus with a Special Focus on Moderate Disease

Article References: Costanzo, A., Campanati, A., Esposito, M., Ferrucci, S. M., Girolomoni, G., Patruno, C., Pezzolo, E., Ribero, S., Rossi, M., Stingeni, L., Marzona, I., Politi, L., Napolitano, M., AD Delphi Working group, Susca, S., Arese, V., Leporati, C., di Vico, F., Marasca, C., … Trave, I. (2026). Current Challenges in Atopic Dermatitis: An Italian Delphi Consensus with a Special Focus on Moderate Disease. Dermatology and Therapy. https://doi.org/10.1007/s13555-026-01952-2

Image Credits: AI Generated

DOI: 10.1007/s13555-026-01952-2

Keywords: atopic dermatitis, Delphi consensus, moderate disease, EASI score, patient-reported outcomes, pruritus, quality of life, reimbursement, Italy, dermatology, systemic therapies, unmet needs