Atopic Dermatitis Treatment Strategies Using Ruxolitinib, Considering Crucial Role of Skin Microbiome

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Lawrence F. Eichenfield, MD, FAAD, chief of pediatric and adolescent dermatology at Rady Children's Hospital and professor of dermatology and pediatrics and vice chair of the department of dermatology at the University of California San Diego School of Medicine, discussed ruxolitinib cream as a potent, nonsteroidal topical option for atopic dermatitis, noting its efficacy even on delicate skin areas and its potential to prevent the need for systemic therapies in some patients.

He emphasized the role the skin microbiome plays in eczema pathogenesis, particularly the correlation between Staphylococcus (Staph) aureus counts and disease severity in an interview with The American Journal of Managed Care at the American Academy of Dermatology 2025 annual conference. Eichenfield explained that effectively controlling atopic dermatitis, whether with topical or systemic therapies, positively impacts the microbiome by reducing cutaneous infections, demonstrating the microbiome's responsiveness to anti-inflammatory care.

This transcript was lightly edited for clarity; captions were auto-generated.

Transcript

How do you determine which patients with atopic dermatitis are appropriate candidates for ruxolitinib cream, particularly in the context of step therapy requirements and prior treatment failures?

Ruxolitinib cream basically sits as a nonsteroidal option and with very good potency. We know from the phase 2 ruxolitinib trial that the topical ruxolitinib 1.5% outperformed triamcinolone 0.1% cream. They had that comparator arm.

I think in clinical practice, we see that as well. It brings a potency that is a little bit stronger than a mid-potency topical corticosteroid, and with practical use, where you can use it on pretty much any cutaneous surface. You can use it on delicate skin areas like face, periocular areas, or you can use it in body folds, areas where you might have problems with atrophy. It becomes a highly reliable go-to nonsteroid with high efficacy that can be used broadly.

With the proviso that you have, you limit the body surface area to 20% of the body surface area, because we know that the performance of the drug from a safety standpoint that does very well within those parameters.

What is your experience with the efficacy and safety profile of ruxolitinib cream in pediatric and adolescent patients? How does it compare with other systemic therapies?

It's an interesting question to say, "how does a topical perform and how does it do in relationship to systemic agents in terms of either efficacy or side effect profile?" Topical ruxolitinib sits with this incredible potency as a topical agent, there are definitely patients who will respond to topical ruxolitinib and maybe prevent them from the need to go to systemic therapy.

We have other patients who are sometimes off-label on other systemic therapies, such as biologic agents. We add ruxolitinib to their regimens of care, if we can get it approved, because it may manage, for instance, remnant facial dermatitis.

Ruxolitinib is pretty consistent in terms of its clinical response and efficacy. It's rare that we have a topical where patients come back incredibly happy with its ability to suppress their disease, with very rapid and potent response on itch as well. There are some patients where that may end up being monotherapy, and other patients where we're using it intercalating with other traditional topical corticosteroids, or, as mentioned, occasionally, with systemic medicines as well.

There's growing interest in the skin microbiome's role in pediatric dermatoses. How do you see this impacting future treatment strategies?

The skin microbiome is very involved in part of the pathogenesis and clinical manifestations of eczema. We've known for decades that when eczema gets worse, the Staph aureus counts go up. If Staph aureus is more present, the eczema can be more severe as well.

That translates to clinically impetiginized atopic dermatitis as well. How this gets initiated. We're not there yet. Different models of research show that it could be that Staph aureus precedes atopic dermatitis and other early studies the other way around. Once you have established atopic dermatitis, often, very commonly, we can have severe flares of the disease associated with clinical cutaneous infection.

What's interesting is that, if you adequately control the skin with skin-directed therapy, with topical agents, or with systemic agents, such as at least 2 biologic therapies that have been studied, dupilumab and tralokinumab. Whether it be topical or systemic therapy, if you get the disease under control, you'll decrease cutaneous infections, and that has an impact on the microbiome. The microbiome is responsive, it's not static; but we have ways of influencing it. If you have effective anti-inflammatory care, you'll often have [an] impact [on] changing or decreasing the amount of secondary cutaneous infections.