When eczema will not respond, question the diagnosis first

The edition in brief

The American Academy of Dermatology has issued a Good Practice Statement on the diagnostic workup of adults with presumed atopic dermatitis that has not responded to optimised treatment. Its central premise is that non-response should prompt reconsideration of the diagnosis or a search for a concomitant condition, rather than further escalation. The workgroup used GRADE methodology but is explicit that direct empirical data on diagnostic strategies in this situation do not exist, so the statement rests on indirect evidence and consensus. REZOLVE-AD, a phase 2b trial in 393 biologic-naive adults with moderate-to-severe atopic dermatitis, tested rezpegaldesleukin, an interleukin-2 receptor agonist that expands regulatory T cells. All three dose arms met the primary endpoint. Mean EASI change at 16 weeks was -61%, -58% and -53% against -31% for placebo, with treatment differences of 30, 27 and 22 percentage points. Injection-site reactions occurred in 70% versus 4%, almost all mild to moderate. A systematic review of 68 studies and 15,427 patients across five inflammatory skin diseases found oral JAK inhibitors achieved EASI-75 in 38 to 73% in atopic dermatitis, PASI-75 in 33 to 67% in psoriasis, and SALT-50 in 30 to 62% in alopecia areata, with upper respiratory infection in 5 to 14% and herpes zoster reactivation in 1 to 3%. The BIOBADADERM registry, covering 4,820 patients and 20,829 patient-years, found serious infections uncommon overall at 5.33%, with Candida infection commoner on the interleukin-17 pathway agents. Today's pearl: before escalating in refractory eczema, take a scraping and a patch test history.