Experts urge earlier JAK inhibitor use in AD and vitiligo | Fall Clinical Derm 2026

It’s recommended by several experts that dermatologists stop prescribing systemic steroids for atopic dermatitis (AD) and reach sooner for JAK inhibitors and nonsteroidal creams. At the Fall Clinical Dermatology Conference on Oct. 8, experts in the space also said the safety concerns behind the JAK class's boxed warning have been overstated.

These ideas could affect the order in which health plans cover these drugs. Speakers in Friday’s general session said any course of steroid pills or shots should count as a first try at systemic treatment. They also urged doctors to aim for nearly clear skin, not just some improvement, and to keep people with vitiligo on JAK inhibitors for the long term.

AbbVie funded the AD session through an educational grant. The company makes the JAK inhibitor Rinvoq (upadacitinib), and much of the safety data shown in the session focused on that drug.

The case against systemic steroids

The American Academy of Dermatology (AAD) conditionally recommends against systemic steroids for AD in both adults and children. However, about half of patients with AD receive them, as do three-quarters of those with moderate to severe disease, according to Ruth Ann Vleugels, M.D., M.P.H., M.B.A., chair of dermatology at Penn Medicine.

One patient she treated had been through 25 prednisone tapers and she said she never gives systemic steroids for AD.

Christopher Bunick, M.D., Ph.D., an associate professor of dermatology at Yale School of Medicine, cited a study linking even a six-day course of oral steroids to higher rates of sepsis, blood clots and fractures for up to 90 days afterward.

Bunick pointed to a published expert consensus, which he said he helped develop, on limiting systemic steroids in AD. It says courses should last no more than three to four weeks. The consensus also says any systemic steroid exposure, including a single injection or a course of six days or less, should count as a systemic therapy trial. Completing that trial should immediately qualify a patient to move to an advanced therapy, such as a biologic or an oral JAK inhibitor.

Revisiting the boxed warning

The FDA added a boxed warning to JAK inhibitors in 2021 after ORAL Surveillance, a trial comparing Xeljanz (tofacitinib) with TNF inhibitors in patients with rheumatoid arthritis who were 50 or older and had at least one heart risk factor. The warning covers major heart events, blood clots, cancer, serious infections and death, and it remains on the labels.

Bunick called ORAL Surveillance “one of the most misunderstood and misinterpreted studies ever." He noted that it was open-label and had no placebo group, and he said every patient was also taking methotrexate. He cited a reanalysis that found the extra heart risk with tofacitinib appeared only in patients with a history of hardened arteries.

He also presented long-term AD data for upadacitinib (seven years) and Cibinqo (abrocitinib, six and a half years), totaling about 17,000 patient-years. Rates of major heart events, clots and cancer were similar to or lower than those in a real-world Kaiser Permanente group of patients with moderate to severe AD. These are comparisons across separate groups, not randomized results.

Vleugels said she still screens every patient. She asks whether they have had a blood clot, a heart attack or stroke, or cancer, and she encourages the shingles vaccine because JAK inhibitors raise shingles risk. Vleugels added that she orders labs at baseline and about every four to six months. None of those histories is an automatic exclusion, she said. They help her weigh each patient's risk.

She said she often sees patients who were denied a JAK inhibitor because they take birth control pills. Upadacitinib data show no added clot or heart risk in those patients, she said.

When to switch

Diego Ruiz DaSilva, M.D., a dermatologist at Forefront Dermatology, said he switches patients to a JAK inhibitor when a biologic causes side effects such as facial redness or eye problems, or when patients worry about the long-term safety of older immune-suppressing drugs. Patient preference is often the deciding factor. Military service members facing deployment, college students and people without reliable refrigeration may struggle to stay on an injectable biologic.

Regardless of the drug, he said, clinicians should reassess at three to six months and aim for minimal disease activity, meaning nearly clear skin and little to no itch, rather than settling for partial improvement.

Bunick cited a 28-country real-world study that found reaching minimal disease activity was linked to 80% fewer flares and 61% fewer AD-related healthcare visits.

Vitiligo: JAKs for the long haul

In a separate session supported by Incyte, which makes ruxolitinib cream and is developing povorcitinib, two vitiligo specialists said JAK inhibitors are now the only targeted treatment option for the disease. "You got to embrace the JAKs," Abrar Qureshi, M.D., M.P.H., chief of dermatology at Brown University, said.

The Opzelura (ruxolitinib) cream is the only FDA-approved vitiligo drug so far. Qureshi said he expects upadacitinib to become the first approved oral option within weeks. AbbVie filed for approval in February. Litfulo (ritlecitinib) and povorcitinib also posted positive phase 3 results this year.

The speakers stressed that results take far longer than in AD. Ruxolitinib cream's main trial endpoint was eight weeks in AD but 24 weeks in vitiligo, and oral trials ran close to a year. The immune attack has to be stopped first, and then pigment cells return slowly.

Iltefat Hamzavi, M.D., a vitiligo specialist in Detroit, said repigmentation kept improving through two years of treatment. Hamzavi said patients generally need to stay on therapy, possibly at a lower intensity over time, because stopping for too long can lead to lost response. Adding narrowband ultraviolet light therapy further improved results in studies he reviewed.

On safety, Qureshi noted that patients in vitiligo trials were mostly in their 30s and 40s, while ORAL Surveillance enrolled older, sicker patients. The boxed warning's heart, clot and cancer risks are tied largely to patients 50 and older, he said, so many people with vitiligo start from a lower baseline risk.

More options before systemic therapy

For milder AD, speakers in another session urged moving patients off long-term topical steroids. “I think of topical steroids as a short-term solution to a long-term problem,” Linda Stein Gold, M.D., director of dermatology clinical research at Henry Ford Health System, said.

The nonsteroidal options have grown. They include ruxolitinib cream, Vtama (tapinarof) cream and three topical phosphodiesterase-4 inhibitors: Eucrisa (crisaborole), Zoryve (roflumilast) cream and Adquey (difamilast) ointment, which the FDA approved this year. Unlike ruxolitinib cream, which is limited to 20% of body surface area and short-term or intermittent use, several of the newer agents carry no limits on how much skin or how long they can be used, Stein Gold said.

The drugs differ in age range, dosing and base, and Stein Gold said the best choice is often the one a patient will actually use. Crisaborole is approved for infants as young as 3 months and roflumilast is applied once daily rather than twice.

Brad Glick, D.O., M.P.H., who directs the dermatology residency at Larkin Health System, noted that even access to older nonsteroidal options such as topical calcineurin inhibitors is not guaranteed.