Choosing a Systemic Treatment for Elderly Patients with Atopic Dermatitis

Mathieu et al evaluated systemic treatments of atopic dermatitis in elderly patients (≥ 65 years of age) prospectively in a multicenter observational study in France.¹ They found similar improvements in disease severity and quality of life compared to younger adults. These outcomes were achieved with mostly the administration of biologics, and they found a high treatment persistence.

Background and Study Results

Atopic dermatitis (AD) is a common chronic inflammatory dermatosis. While AD is most commonly seen in children, it is increasingly recognized in adults. A recent meta-analysis estimated a point prevalence of adult AD at 6.3% globally.² Despite this, the older adult population remains under-represented in clinical trials of AD therapies.³ As a result, there is less information about this population available, and dermatologists may hesitate to initiate systemic therapies in elderly patients, leading to poorly controlled disease in this population. This prospective study from a French cohort addresses this gap by evaluating real-world impact of systemic treatment choices in the elderly (≥ 65 years of age) vs younger adults.

A total of 679 adults with AD were included (83 elderly participants and 596 younger adults). Prior to enrollment, 74.7% of elderly patients and 73.5% of younger adults were managed with topical therapy alone. The baseline Eczema Area and Severity Index (EASI) scores were comparable (mean, 18.3 ± 11.9).

Biologic therapies were initiated in most cases as the systemic treatment of choice in this study, though there was some disparity: 72.3% of elderly vs 54% of younger patients. Elderly patients were much less likely to receive a JAK inhibitor than younger patients, with the percentages being 8.4% vs 26.4%, respectively, possibly reflecting real-world acknowledgement of the different adverse effect profiles.

Across the entire cohort, clinical improvement was marked. At 12 months, the mean EASI score decreased from 17.6 to 3.7 in the elderly patients and from 18.4 to 4.3 in younger patients, without a significant difference in treatment response between the age groups. Hospitalization declined in both groups, and quality of life measures improved similarly across ages. One notable difference is that elderly patients had excellent treatment adherence, with zero elderly patients classified as non-compliant at the 12-month mark vs 6.4% of younger adults.

Utilized therapies included biologics, JAK inhibitors, and systemic immunomodulators (defined in the study as methotrexate, ciclosporin, azathioprine, mycophenolate mofetil, and retinoids). As for outcomes, the biologic therapies demonstrated strong results. Treatment maintenance at 12 months was 89.6% in elderly patients and 93% in younger adults, and EASI scores fell from 17.9 to 3.4 in the elderly patient population. When discontinuation did occur, it was due to lack of efficacy rather than adverse events, which is an encouraging finding that emphasizes the safety of using biologics in this patient population.

On the other hand, JAK inhibitors were prescribed less frequently in older adults but showed comparable maintenance rates of 75% across age groups. Only two elderly patients in the study discontinued the medication (one for patient preference and the other for inefficacy). Systemic immunomodulators such as methotrexate had a much higher discontinuation rate (50% to 70%), mostly due to inefficacy and adverse events.

Comments and Clinical Implications

This study contributes important data on systemic AD treatment in older adults. The findings challenge long-held fears about using systemic agents in the elderly population. This paper provides real-world data demonstrating that biologics are both effective and safe, with high treatment persistence and significant improvement in disease burden. 

The study also highlights the powerful effect of a therapeutic change from topical agents alone to a systemic agent in these patients. Although JAK inhibitors were used more cautiously in older adults, the limited data here suggest that these agents can be utilized successfully in this population.

Limitations include the lack of mild AD patients and the relatively small numbers. However, strengths include patient-reported outcomes as well as dermatologist-confirmed diagnoses.

In conclusion, the study supports proactive, evidence-based systemic AD management in elderly patients to improve the quality of life and disease severity, while doing so safely. 

Disclosures: Laila Barkoudeh reports no relevant financial interests. Dr. Peter Lio reports being on the speaker’s bureau for AbbVie, Arcutis, Eli Lilly, Galderma, Hyphens Pharma, Incyte, La Roche-Posay/L’Oreal, Pfizer, Pierre-Fabre Dermatologie, Regeneron/Sanofi Genzyme, Verrica; reports consulting/advisory boards for Alphyn Biologics, AbbVie, Almirall, Amyris, Apogee, Arcutis, ASLAN, Astria Therapeutics, Castle Biosciences, Codex Labs, Concerto Biosci, Dermavant, Eli Lilly, Galderma, Kenvue, LEO Pharma, Lipidor, L’Oreal, Merck, Micreos, MyOR Diagnostics, Nektar Therapeutics, Nia Health, Pelthos Therapeutics, Phyla, Regeneron/Sanofi Genzyme, Sibel Health, Skinfix, Song Lab Skincare, Soteri Skin, Stratum Biosciences, Sun Pharma, Theraplex, Thimble Health, Topaz Biosciences, UCB, Unilever, Verdant Scientific, Verrica, Yobee Care. Stock options with Akeyna, Inc., Alphyn Labs, Codex Labs, Concerto Biosci, Song Lab Skincare, Soteri Skin, Stratum Biosciences, Thimble, Topaz Biosciences, Yobee Care, Verdant Scientific.  In addition, Dr. Lio has a patent pending for a Theraplex product with royalties paid and is a Board member and Scientific Advisory Committee Member emeritus of the National Eczema Association.

1. Mathieu C, Maccari F, Perrot JL, et al. Clinical impact of systemic treatment choices made in current practice in elderly patients with atopic dermatitis. Acta Derm Venereol. 2025;105:adv44174. Published 2025 Oct 30. doi:10.2340/actadv.v105.44174

2. Migliavaca CB, Lazzarini R, Stein C, et al. Prevalence of atopic dermatitis: a systematic review and meta-analysis. Dermatitis. 2025;36(6):575-582. doi:10.1089/derm.2024.0165

3. Hall EH, Noon H, Hemmerich C, et al. Addressing diversity gaps in atopic dermatitis clinical trials: a systematic review and meta-analysis. Poster presented at: 2024 Symposium on Tribal and Rural Innovations in Disparities and Equity for Health; September 13, 2024; Tahlequah, OK.