The heterogeneity of atopic dermatitis pathophysiology necessitates strategic patient selection when implementing targeted biologic therapies.1 While type 2 inflammation predominates in most patients with moderate-to-severe disease, phenotypic and endotypic variations influence treatment responses.1-3M Biomarkers offer potential to enhance diagnosis, assess disease status and severity, and enable tailored treatment options for patients beyond traditional clinical rating scales.1-3 Understanding which patients will derive greatest benefit from selective IL-13 inhibition versus other therapeutic modalities remains an area of active investigation.1-3
Periostin and dipeptidyl peptidase-4 have been identified as biomarkers for IL-13 activity and demonstrate association with response to IL-13 inhibitor treatment.4 Elevated serum levels of these markers have been found in patients with Eczema Area and Severity Index (EASI) scores below the traditionally accepted cut-off of 16, suggesting patients may respond favorably to selective IL-13 inhibition and a need to revisit established thresholds for treatment.4,5 However, biomarker-guided treatment selection remains investigational, and most clinicians rely on clinical phenotyping to identify appropriate candidates. Patients with chronic lichenified plaques, significant pruritus despite optimized topical therapy, and inadequate response to or contraindications for other systemic approaches represent ideal candidates for IL-13 targeted therapy.1,3
Early systemic intervention may minimize systemic inflammation, disrupting the itch-scratch cycle and managing the root cause of pruritis.6,7 Traditional treatment algorithms often reserve systemic therapies for patients who have failed multiple topical approaches, yet this stepwise escalation may allow establishment of chronic inflammatory pathways that prove more resistant to intervention.6,7Systemic therapies, such as selective IL-13 inhibitors, offer favorable safety profiles that support chronic administration, allowing clinicians to prioritize disease control over preservation of the traditional treatment hierarchy. As understanding of atopic dermatitis phenotypes advances, biomarker-driven selection algorithms will refine patient identification, but clinical judgment regarding disease burden and functional impairment remains paramount in current practice.1-3
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