By the time a biologic or a JAK inhibitor is being discussed, the question is rarely which drug performs best in the abstract. It is which one the NHS will fund for you, in what order, and how much of that order rests on comparative evidence rather than on price and licensing. NICE's technology appraisals answer the first part. The comparative trial evidence answers the second, and it is thinner than the number of licensed drugs suggests.
Whether a systemic drug is the right step at all, and how each class works at the receptor, is covered separately in dupilumab and biologics for eczema. This post is about choosing between them.
The appraisals set the order, one drug group at a time
NICE has assessed these treatments in batches, and the resulting appraisals are the frame a UK dermatologist works inside:
- TA534, dupilumab, published 1 August 2018
- TA814, abrocitinib, tralokinumab or upadacitinib, published 3 August 2022
- TA986, lebrikizumab, published 10 July 2024
- TA1077, nemolizumab, published 2 July 2025
Baricitinib sits in the same pathway under its own earlier appraisal. NICE's summary of where all of them fall is short: after an inadequate response or intolerance to at least one systemic treatment, "a biological medicine (dupilumab or tralokinumab) or a Janus kinase (JAK) inhibitor (abrocitinib, upadacitinib or baricitinib) is offered" (NICE TA986, 2024).
One gate for everything, then a second gate for the newest drugs
TA814, TA986 and TA1077 open with the same condition. Abrocitinib, tralokinumab and upadacitinib are recommended only if "the disease has not responded to at least 1 systemic immunosuppressant, or these are not suitable" (NICE TA814, 2022). Lebrikizumab and nemolizumab repeat it almost word for word.
The two most recent drugs then carry a second condition that the older ones do not. Lebrikizumab is funded only if dupilumab or tralokinumab would otherwise be offered (NICE TA986, 2024), and nemolizumab only if "a biological medicine would otherwise be offered" (NICE TA1077, 2025). That is a sequencing rule rather than a verdict on which drug works better. It means the newest agents enter as alternatives to the established antibodies, not ahead of them, so in practice the first advanced treatment discussed is usually dupilumab or tralokinumab.
Age and weight narrow the list before efficacy does
The licences differ, and the appraisals follow them. Abrocitinib and upadacitinib are recommended for "adults and young people 12 years and over", while tralokinumab is recommended for adults only (NICE TA814, 2022). Lebrikizumab requires a body weight of 40 kg or more in people 12 and over (NICE TA986, 2024), and nemolizumab requires 30 kg or more in the same age band (NICE TA1077, 2025).
For a 13-year-old weighing 35 kg, that arithmetic removes tralokinumab and lebrikizumab before anyone opens a trial result. It is worth asking which drugs are actually available to you before comparing the ones that are not.
What has been compared directly, and what has not
Heads Up is the trial people mean when they talk about head-to-head evidence in eczema. It was "a 24-week, head-to-head, phase 3b, multicenter, randomized, double-blinded, double-dummy, active-controlled clinical trial" comparing oral upadacitinib 30 mg once daily with subcutaneous dupilumab 300 mg every other week in 692 adults with moderate-to-severe atopic dermatitis who were candidates for systemic therapy, run at 129 centres across 22 countries. The primary endpoint was a 75% improvement in the Eczema Area and Severity Index at week 16, which more patients reached on upadacitinib than on dupilumab (Blauvelt et al, 2021). The numbers it produced are reported in the biologics overview.
Most other pairings have never been tested that way. When NICE assessed the three drugs in TA814, its committee recorded that abrocitinib, upadacitinib and tralokinumab "were each directly or indirectly compared with dupilumab and baricitinib for use after systemic immunosuppressants, but the results are uncertain" (NICE TA814, 2022). Lebrikizumab reached the same place two years later through a network meta-analysis in which "there was no statistically significant difference between lebrikizumab and abrocitinib, dupilumab, tralokinumab or upadacitinib 15 mg" (NICE TA986, 2024).
Two things follow from that. Confident claims that one antibody beats another are usually built on indirect comparison, and the appraisal committees that read those comparisons described them as uncertain.
Itch is scored separately, and the ranking is not identical
The best pooled source is a living network meta-analysis covering 60 trials and 16,579 patients (Drucker et al, 2022). Its EASI results sit in the biologics overview, but the itch column is worth reading on its own, because itch and skin severity do not always move together.
On the peak pruritus numeric rating scale after 8 to 16 weeks of treatment, abrocitinib 200 mg daily and upadacitinib 30 mg daily were slightly better than dupilumab, upadacitinib 15 mg daily showed little or no difference, and baricitinib at 2 mg and 4 mg and tralokinumab were slightly worse, all at high certainty. The Patient Oriented Eczema Measure followed a similar pattern. Lebrikizumab entered that 2022 update with a single phase 2b trial, too little to draw conclusions from, which is why its position rests on the later NICE analysis instead.
Price separates drugs the evidence cannot
The appraisals publish list prices. Abrocitinib was £893.76 for a 28-pack of 100 mg or 200 mg tablets, tralokinumab £1,070 for a 4-pack of 150 mg pre-filled syringes, and upadacitinib £805.56 for a 28-pack of 15 mg tablets or £1,611.12 for 30 mg, all excluding VAT and taken from BNF prices accessed in March 2022 (NICE TA814, 2022).
Those are not the prices the NHS pays. Each company has a commercial arrangement giving a discount whose size is "commercial in confidence", disclosed to relevant NHS organisations. NICE then instructs that where a drug is one of a range of suitable treatments, "the least expensive should be used" (NICE TA986, 2024). So when the comparative evidence cannot separate two agents, the tiebreak is a figure that is not published.
Sixteen weeks, and two adjustments to the scoring
Funding is conditional on measured response. Treatment stops at 16 weeks if the response is inadequate. An adequate response is "at least a 50% reduction in the Eczema Area and Severity Index score (EASI 50) from when treatment started" together with "at least a 4-point reduction in the Dermatology Life Quality Index (DLQI)" (NICE TA814, 2022). TA986 and TA1077 apply the same rule.
Two instructions in the same appraisal rarely get mentioned. NICE tells clinicians to "take into account how skin colour could affect the EASI score, and make any appropriate adjustments", and to allow for "any physical, psychological, sensory or learning disabilities, or communication difficulties that could affect the responses to the DLQI" (NICE TA814, 2022). EASI scores redness, which presents differently on darker skin, and DLQI is a self-completed questionnaire. Both feed a decision about whether treatment continues, so both are better raised before the baseline scores are taken than after the week 16 review.
What is left for the clinic to decide
Once the appraisal criteria, your age and weight, and your other conditions have been applied, what remains is usually a choice about rhythm and monitoring rather than about a few points of EASI: a daily tablet with blood tests, or an injection every two or four weeks. That choice belongs to the dermatology team, made with your scores and history in front of them.
Getting to that conversation is a referral question first, and every appraisal above assumes the topical routine was genuinely optimised before it was called a failure, which is where most routines stall.
References
- Blauvelt A, Teixeira HD, Simpson EL, et al. Efficacy and safety of upadacitinib vs dupilumab in adults with moderate-to-severe atopic dermatitis: a randomized clinical trial. JAMA Dermatology, 2021, 157(9):1047. https://doi.org/10.1001/jamadermatol.2021.3023
- Drucker AM, Morra DE, Prieto-Merino D, et al. Systemic immunomodulatory treatments for atopic dermatitis: update of a living systematic review and network meta-analysis. JAMA Dermatology, 2022, 158(5):523. https://doi.org/10.1001/jamadermatol.2022.0455
- National Institute for Health and Care Excellence. Dupilumab for treating moderate to severe atopic dermatitis. Technology appraisal guidance TA534, 2018. https://www.ncbi.nlm.nih.gov/books/NBK619772/
- National Institute for Health and Care Excellence. Abrocitinib, tralokinumab or upadacitinib for treating moderate to severe atopic dermatitis. Technology appraisal guidance TA814, 2022. https://www.ncbi.nlm.nih.gov/books/NBK615426/
- National Institute for Health and Care Excellence. Lebrikizumab for treating moderate to severe atopic dermatitis in people 12 years and over. Technology appraisal guidance TA986, 2024. https://www.ncbi.nlm.nih.gov/books/NBK611956/
- National Institute for Health and Care Excellence. Nemolizumab for treating moderate to severe atopic dermatitis in people 12 years and over. Technology appraisal guidance TA1077, 2025. https://www.ncbi.nlm.nih.gov/books/NBK617252/