Global Survey Reveals Wide Variation in How Dermatologists Start Biologics for Eczema

Dermatologists around the world start their patients on biologic therapies for moderate-to-severe atopic dermatitis in strikingly different ways, according to a new international project that surveyed 150 clinicians across North America, Europe and Japan. The initiative, known as the AMAZE project, combined an online survey, a narrative literature review, regional expert meetings and a global steering committee to map real-world practice and produce expert-informed recommendations for initiating and managing biologic therapy in routine care. The findings, published in Dermatology and Therapy, highlight how local guidelines, reimbursement rules and personal preference shape decisions at every step, from the first prescription to long-term follow-up.

The survey respondents were experienced prescribers by design. Participants were screened to ensure that they spent more than 60 percent of their working time in direct patient care, had experience prescribing biologics, and had recently initiated at least five patients with moderate-to-severe atopic dermatitis on a biologic in the preceding three months, or at least three patients in Japan, reflecting the later availability of these products there. Forty percent of respondents practiced in North America, 47 percent in Europe and 13 percent in Japan. The data were collected through a double-blinded online survey completed in local languages during October and November 2024, with all participants providing informed consent and receiving fair-market-value compensation. Data collection was facilitated by Gerson Lehrman Group through its network of independent experts.

The global steering committee that steered the project comprised six dermatologists and a nurse practitioner practicing in the USA, Canada, the UK, Italy and Poland, selected for their clinical and research expertise in moderate-to-severe atopic dermatitis and for broad geographic representation. The committee first met virtually on 8 May 2024, informed by an initial literature review and limited insights from two US patients about their experiences of starting biologics, including expectations, education and perceived barriers. From this, the committee identified key areas of uncertainty: when to initiate biologics, patient communication and education, transitioning from conventional systemic immunosuppressives, monitoring safety and efficacy, and supporting long-term adherence. Four virtual expert discussion meetings followed in April and May 2025, bringing together 15 dermatologists from South Korea, Denmark, the United Arab Emirates, Switzerland, Sweden, the Netherlands, Belgium and Japan, before the committee reconvened on 17 June 2025 to consolidate the recommendations.

One of the clearest signals from the survey concerned intended treatment duration. Overall, 47 percent of dermatologists intended biologic therapy for long-term use, defined as at least one year, while nearly a quarter said they had no prespecified treatment duration in mind. Respondents in Japan were more likely to anticipate shorter treatment durations of four to twelve months, a pattern the authors attribute to Japanese guideline recommendations, which state that discontinuation of a biologic may be considered if remission is maintained by combination therapy with a biologic and a topical corticosteroid or topical calcineurin inhibitor, with six months used as a guide for when to consider stopping. Just over half of respondents, 56 percent, said treatment duration was considered during the decision-making process, whereas 26 percent discussed it with patients only at or just after the start of treatment.

Transition practices from conventional systemic therapies varied substantially between dermatologists and regions. When switching from a conventional systemic therapy to a biologic, 49 percent of respondents reported overlapping the two treatments, 33 percent transitioned patients directly without overlap, and 18 percent used a washout period between treatments. European clinicians were more likely to discontinue conventional systemic therapies before biologic initiation, whereas overlapping strategies were more common in North America and Japan: overlap was the most frequent approach for 80 percent of Japanese respondents and 63 percent of North American respondents, but only 32 percent of European respondents. Treatment targets were rarely used to guide the duration of overlap, cited by just 8 percent of respondents for conventional systemic therapy. When switching from an oral Janus kinase inhibitor, 29 percent left a washout period, 41 percent transitioned directly and 31 percent overlapped the treatments.

The pathways by which patients reach a biologic also differed by region. Across all respondents, patients most frequently transitioned to a biologic from a topical therapy, at 47 percent, followed by a conventional systemic therapy at 29 percent, a different biologic at 13 percent and an oral JAK inhibitor at 9 percent. The high proportion transitioning from topical therapy was primarily driven by clinical practice in North America and Japan, whereas transitioning from a conventional systemic therapy was more common in Europe, possibly driven by formulary restrictions and reimbursement guidelines. Variability extended to transitions between biologics, with 50 percent of respondents in both Europe and Japan, but only 26 percent in North America, reporting inclusion of a washout period.

Follow-up timing after starting a biologic showed equally wide variation. Overall, 36 percent of dermatologists reported seeing patients within four weeks of initiation and 56 percent within eight weeks. Early follow-up within four weeks was most common in Japan, largely owing to healthcare system requirements, including reimbursement and institutional rules that encourage early visits for injection training and safety monitoring. Personal preference was the main driver of follow-up timing overall, reported by 44 percent of respondents, particularly in North America and Japan, followed by best practice within the clinic or unit at 23 percent, which was the main driver in Europe. The primary purpose of the first visit was assessment of treatment effectiveness for 46 percent of respondents and monitoring for potential adverse events for 15 percent.

The expert committee cautioned that a four-week follow-up is very early for judging effectiveness, because biologics are not expected to provide immediate relief of signs and symptoms, and early assessment of effectiveness could raise patient expectations about the speed of response. This contrasts with oral JAK inhibitors, where rapid responses are expected and early visits can be used to assess adherence. The experts noted that early follow-up may still be relevant in specific situations, such as reviewing self-injection technique, confirming drug receipt in regions with complex supply chains, monitoring patients with very severe disease who may need concomitant treatment while the biologic takes effect, or assessing patients with significant conjunctivitis at baseline. In Japan and South Korea, early first follow-up is mandated, but not for effectiveness assessment; in Japan, week-four visits are specifically used for injection training. If patients show a lack of effectiveness, switching or discontinuing the biologic was considered after around 18 to 20 weeks of treatment in North America or Europe, but after approximately 13 weeks in Japan.

The resulting best practice recommendations address four areas where the steering committee judged existing guidance to be unclear or inconsistent: treatment goals and expectations, transitioning to biologics, follow-up after starting treatment, and managing flares and concomitant medications. The experts recommended establishing patient-centered treatment goals focused on long-term disease control, with clear communication that biologics provide long-term disease management rather than a cure, and agreed that treatment response should be formally assessed around 12 to 16 weeks after initiation using both clinician- and patient-reported outcomes such as body surface area, EASI, investigator global assessment, dermatology life quality index, peak pruritus numerical rating scale and sleep disturbance numerical rating scale, recognizing that some patients may respond later than others. During the maintenance phase, follow-up visits should be scheduled every six months, or as clinically indicated, to monitor efficacy, safety and adherence.

On flares and concomitant therapy, the survey found that most respondents, 83 percent, regularly discussed emollient use with patients receiving biologics, while 56 percent advised patients to gradually reduce topical corticosteroids or calcineurin inhibitors alongside the biologic, and 33 percent recommended ongoing concomitant topical treatment, an approach taken by 55 percent of respondents in Asia. For patients experiencing a flare while on a biologic, 74 percent of respondents recommended emollients and 73 percent prescribed topical therapies, whereas only 22 percent prescribed additional systemic therapies, and 32 percent considered switching between biologics if flares were significant or frequent. The experts advised against premature switching between biologics, citing evidence of reduced effectiveness with successive treatments, and instead recommended optimizing the existing biologic through concomitant treatment and proactive use of emollients or topical therapy at the first sign of even minor flares. The authors acknowledge limitations: the sample was small and self-selecting, biologic-experienced dermatologists are more likely to work in secondary or tertiary care, the limited sample size prevented meaningful statistical analysis, and the study covered only treatments approved at the time. They emphasize that the recommendations rest substantially on expert consensus, reflecting an ongoing evidence gap in the practical use of biologics for atopic dermatitis, and call for pragmatic, prospective studies to evaluate how commonly used transition and follow-up strategies affect treatment persistence, safety and sustained disease control.

Subject of Research: Global clinical practices and expert recommendations for initiating biologic therapy in moderate-to-severe atopic dermatitis

Article Title: Initiating Biologics in Atopic Dermatitis: Global Practices and Recommendations from the AMAZE Project

Article References: Armstrong, A. W., Kim, H. J., Pink, A. E., Gorelick, J., Rossi, M., Trzeciak, M., Deleuran, M., Nakajima, S., & Prajapati, V. H. (2026). Initiating Biologics in Atopic Dermatitis: Global Practices and Recommendations from the AMAZE Project. Dermatology and Therapy. https://doi.org/10.1007/s13555-026-01942-4

Image Credits: AI Generated

DOI: 10.1007/s13555-026-01942-4

Keywords: atopic dermatitis, biologics, dermatology, AMAZE project, dupilumab, tralokinumab, treatment transition, follow-up monitoring, clinical practice variation, shared decision-making, topical therapies, patient education