When to Refer Pediatric AD and Consider JAK Inhibitors

Lisa Swanson, MD, acknowledges that the decision to refer a patient with AD to a dermatologist or allergist is highly individualized, shaped by each pediatric clinician's own comfort level with skin disease. Her general rule: refer whenever AD cannot be brought under control despite sensible skincare and an appropriate topical steroid regimen, or when a family feels overwhelmed by the treatment burden and wants a specialist's input. Undertreated, poorly controlled AD carries real downstream consequences for both patient and family, she notes, which is why she encourages clinicians not to wait too long to send that referral.

She then introduces three newer non-steroid topical options, all now approved down to age two: roflumilast, a phosphodiesterase-4 inhibitor; tapinarof, an aryl hydrocarbon receptor agonist; and topical ruxolitinib, a JAK inhibitor. Swanson describes topical ruxolitinib as matching the efficacy and speed of a topical steroid without being one, applied twice daily to affected areas. It's approved to treat up to 20% of body surface area — she notes that a patient's own hand equals about 1% of body surface area, so families can treat roughly 20 hands' worth of affected skin.

She also addresses the medication's boxed safety warning, which stems from a safety study on an oral JAK inhibitor, tofacitinib, and was subsequently applied by the FDA across the entire JAK inhibitor class — including topical ruxolitinib. To help patients understand this, Swanson uses a pop-culture analogy: topical ruxolitinib is the low-drama member of a famous family, sharing a class label with higher-risk relatives without sharing their risk profile — a framing she says consistently resonates with families.

In the next episode, "What Pediatricians Should Know About JAK Inhibitors Before Referral," Swanson widens the lens to the full JAK inhibitor toolbox — topical and oral — and what pediatricians should understand about each before making a referral.