How has the AAD atopic dermatitis guideline changed your threshold to start systemic therapy rather than rotating topicals in a child with persistent atopic dermatitis despite good adherence?

For me, this has not changed my practice as I have always started systemic therapy early in patients with atopic dermatitis. I find these new updated guidelines reinforce what I believe to be the correct practice. Although we don't have a perfectly matched set of guidelines for AD as we do with psoriasis, following the IPC guidelines for when to initiate systemic therapy makes sense: 10% BSA or involvement of a specialty site or 2 consecutive 4-week trials of topicals. Additionally, it's important to recognize that systemic therapy has the benefit of controlling systemic inflammation and prophylactically preventing or decreasing flares, whereas topicals don't offer these advantages.