Abstract

Atopic dermatitis (AD) is the most prevalent chronic inflammatory skin disease in childhood, and is characterized by complex interactions between genetic susceptibility, epidermal barrier dysfunction, immune dysregulation, and environmental triggers. Recent advances in understanding its immunopathogenesis, particularly the central role of the Th2 axis and the neuroimmune circuitry of itch, have driven a paradigm shift in therapy from conventional symptomatic approaches to mechanism-based strategies. Conventional treatments, including emollients, topical corticosteroids, and calcineurin inhibitors, remain essential but are often insufficient in moderate-to-severe forms. The advent of biologics, most notably dupilumab, has revolutionized pediatric AD management, demonstrating sustained efficacy and safety across all age groups, including infants. Selective IL-13 inhibitors, such as tralokinumab and lebrikizumab, offer targeted options for children and adolescents who exhibit suboptimal responses or intolerance to dupilumab, while nemolizumab provides a complementary strategy by directly targeting the IL-31/IL-31RA axis to alleviate pruritus. Small molecules, including JAK inhibitors and topical PDE4 inhibitors, further expand the therapeutic armamentarium, although systemic risks necessitate careful monitoring in younger populations. Current evidence underscores the importance of balancing efficacy, safety, and long-term immunomodulatory consequences in clinical decision-making. As the therapeutic landscape continues to expand, head-to-head comparative studies and precision medicine approaches, including biomarker-guided treatment selection, will be crucial to optimize sequencing, combination strategies, and cost-effectiveness. Ultimately, novel biologics and targeted therapies hold the promise not only of durable disease control but also of modifying the natural history of AD, improving quality of life and potentially limiting progression along the atopic march.

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Arianna Giannetti - Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Italy

Federica La Ciacera - Department of Medical and Surgical Sciences, University of Cagliari, AOU Cagliari, Italy

Enrico Vito Buono - Pediatric, University of Parma, Parma, Italy

Giuliana Giannì - Pediatrics Department, Allergology and Immunology, Livorno Ospedali Riuniti, Livorno, Italy

Carlo Caffarelli - Pediatric, University of Parma, Parma, Italy

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Giannetti, A. ., La Ciacera, F., Vito Buono, E. ., Giannì, G. ., & Caffarelli, C. . (2026). Update on Biologic Therapy for Atopic Dermatitis. Italian Journal of Pediatric Allergy and Immunology, 39(4). https://doi.org/10.53151/2531-3916/2025-1673
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