Understanding Clinical Inertia in Atopic Dermatitis: A Mixed-Methods Study of Barriers to Treatment Escalation

Although effective therapies are available for moderate-to-severe atopic dermatitis (AD), many eligible patients do not receive timely treatment escalation. This phenomenon, termed clinical inertia, is well described in chronic internal diseases but underexplored in dermatology. We aimed to quantify clinical inertia in AD and to identify patient-, physician-, and system-level barriers to treatment escalation.

We conducted a cross-sectional mixed-methods study at a tertiary dermatology center between November 2024 and March 2025. Forty adults with moderate-to-severe AD completed validated questionnaires on disease severity (POEM), quality of life (DLQI), treatment satisfaction (TPS), and medication beliefs (BMQ). Semi-structured interviews were conducted with 20 patients and analyzed using thematic content analysis.

Despite moderate-to-severe disease, 30% of patients had not received systemic therapy. Key patient-reported barriers included low treatment expectations, fear of side effects, and acceptance of chronic symptoms. High treatment satisfaction scores were observed even in the presence of severe disease and poor quality of life. Interview data revealed five thematic barriers across patient-, physician-, and system-levels, including therapeutic nihilism, limited access to specialists, and fragmented communication pathways.

This study highlights a multifactorial pattern of clinical inertia in AD, with patient perception, therapeutic communication, and healthcare structures all playing a role. These findings underscore the need for structured shared decision-making (e.g., standardized risk-benefit counseling and written decision aids about systemic options), treat-to-target management (regular POEM/DLQI monitoring with predefined escalation triggers when targets are not met), and system-level improvements (clear referral pathways to AD specialists, adequate follow-up capacity, and streamlined approval processes for systemic therapies) to reduce delays in escalation and improve outcomes. As AD treatment options expand, addressing clinical inertia is critical to ensure timely and equitable care.