'Back to square one' - experiences influencing topical corticosteroid use in paediatric atopic dermatitis.

Atopic dermatitis (AD) is a systemic, multifactorial disease that causes significant morbidity and health care burden in Latin America (LA). Data on AD are scarce in LA. Lack of disease registries and non-standardized study methodologies, coupled with region-specific genetic, immunological, and environmental factors, hamper data collection. A panel of LA experts in AD was given a series of relevant questions to address before a conference. Each narrative was discussed and edited through numerous rounds of deliberation until achieving consensus. Identified knowledge gaps in AD research were updated prevalence, adult-disease epidemiology, local phenotypes and endotypes, severe-disease prevalence, specialist distribution, and AD public health policy. Underlying reasons for these gaps include limited funding for AD research, from epidemiology and public policy to clinical and translational studies. Regional heterogeneity requires that complex interactions between race, ethnicity, and environmental factors be further studied. Informed awareness, education, and decision making should be encouraged.

Attrition of topical calcineurin inhibitor use over time in patients with atopic dermatitis

Background/ObjectivesThe prevalence of atopic dermatitis (AD) has increased significantly in industrialised countries in recent decades but data about the incidence or prevalence of AD in Australia are sparse. We aimed to determine the prevalence and incidence of AD among patients seen in Australian general practice and the use of specified medicines.MethodsThis was a cross‐sectional study of 2.1 million patients attending 494 general practices in the MedicineInsight program from 1 January 2017 to 31 December 2018. We assessed the prevalence (lifetime and current), incidence, management and severity of AD.ResultsThe lifetime (ever diagnosed) prevalence of AD in this general practice population was 16.4% and was greater in females (17.3%) than males (15.3%). One in five patients with AD were classified as having moderate‐to‐severe disease. Prevalence over the last two years was 6.3%. The incidence of AD in 2018 was 2.0% and was greater in females (2.2%) and for patients aged 0–4 years (3.9%). Patients with AD had an increased risk of insomnia, anxiety and depression, compared to those with no recorded AD. For AD patients, topical corticosteroids were the most commonly prescribed AD medication (36.5%) and topical calcineurin inhibitors the least (0.1%), with systemic corticosteroids (15.6%) more commonly prescribed than other immunosuppressants (0.9%).ConclusionsOur findings provide important insights into the epidemiology of AD and its management in Australian general practice. This information is likely to be useful in planning effective interventions to support GPs in the optimal management of patients with AD.

What's new in atopic dermatitis?

Évaluation de la prise en charge de la dermatite atopique de l’adulte en soins primaires

Atopic dermatitis is a complex, recurrent, chronic inflammatory skin condition. It frequently begins to manifest in early childhood and may last throughout adulthood. The need for clinical practice guidelines that are based on evidence is critical for efficient and secure care. Little is known about how primary care providers (PCPs) should handle pediatric and adult atopic dermatitis cases and whether they should follow national recommendations. Our systemic review aimed to examine management strategies for treating adult and pediatric (family) atopic dermatitis, including topical calcineurin inhibitors (TCIs), topical corticosteroids (TCS), skin emollients, oral antihistamines, and diet. Data sources were PubMed (MEDLINE) and Embase. Our review investigated English-language articles from 2014 to 2023 that studied the management of adult and children atopic dermatitis. Overall, there were 15 articles included. Surveys and analyses of national databases were the most widely used methods (n=7). The use of TCS by PCPs was common, but they also overprescribed nonsedating antihistamines, favored low-potency drugs, and avoided TCIs. Most studies relied on healthcare personnel reporting their typical behaviors rather than looking at specific patient encounters and it is considered a limitation. Finally, there are gaps in knowledge and management of critical topics such as prescribing TCIs and understanding the safety profiles of TCS, when it comes to treating adult and pediatric atopic dermatitis. Future research in this area is urgently needed because the current systemic assessment is mostly restricted to small studies that assess prescribing behaviors with scant information describing nonmedication management.

Atopic dermatitis

Background:Atopic dermatitis (AD) is a chronic, pruritic, inflammatory skin disease with a wide range of severity, and is usually the first manifestation of atopic disease. It is one of the most common skin disorders in developed countries, affecting approximately 20% of children and 1–3% of adults. Symptoms such as eczematous papules, plaques, and itch, and their associated consequences, such as sleep disturbance, can significantly impact the quality of life of the patient and family.Scope:This is a broad-based review focusing on clinical practice for primary care physicians treating patients with AD. The PubMed database was searched (to 1 November 2008) for English-language articles containing the keywords atopic dermatitis, atopic eczema, topical calcineurin inhibitor, tacrolimus, pimecrolimus, or corticosteroid. Articles focusing on clinical practice for patients with AD were chosen for further review. A limitation is that this is not a systematic review of the literature.Findings:Emollients have long been used to maintain the skin barrier function in patients with AD. Topical corticosteroids have been the pillar of medicated therapy for AD since their introduction nearly 50 years ago. The introduction of topical calcineurin inhibitors more than 8 years ago represented the first new class of medication approved for the treatment of AD since topical corticosteroids. Topical calcineurin inhibitors provide targeted anti-inflammatory activity without the local or systemic side-effects seen with topical corticosteroids. More recently, three new, nonsteroidal, barrier creams (Atopiclair, Mimyx, and Epiceram) have entered the marketplace for AD treatment. A multi-therapeutic approach that incorporates short-term management of flares and longer-term strategies to prolong the time between flares is needed for the treatment of AD.Conclusion:Multiple topical therapies have been successfully used to treat patients with AD. An understanding of the available treatment options will help primary care providers striving to achieve best practice in the management of AD.

Bleach baths for atopic dermatitis: Evidence of efficacy but more data are needed

Ninety-seven Perth general practitioners completed a self-administered postal questionnaire that aimed to examine their caseload and management practices for childhood atopic dermatitis (AD). General practitioners saw a median of two new cases and three follow-up consultations per month for childhood AD, and referred a median of 10% of cases to a specialist, usually a dermatologist. Most (77%) recommended emollients for all patients, but only 21% specifically reported advising their use immediately after bathing. Sixty-one percent would use topical corticosteroids in all or most patients, but cream preparations were more commonly used (58%) than ointments (40%). Atrophy was rated as a common or very common side-effect of topical corticosteroid therapy by 23% of general practitioners. Twenty-six percent reported using oral corticosteroids in children with AD. Dietary changes would be recommended in at least a few AD patients by 79% of general practitioners, and 31% would recommend a change from cow's milk to soy in the absence of a history of dietary triggers. We conclude that general practitioners appeared generally well informed about AD management. However, dermatologists, through targeted education, may be in a position to help general practitioners further improve outcomes for these patients.

Introduction: Various healthcare professionals (HCPs) deliver care for patients with atopic dermatitis (AD). Although pivotal, management strategies and the relation with corticophobia among HCPs have not been investigated. This study aimed to investigate management strategies for AD and its relation with corticophobia among HCPs. Methods: Dutch general practitioners (GPs), youth healthcare physicians (YHPs), pediatricians, dermatologists, pharmacists, and pharmacy assistants participated in a survey on management strategies and corticophobia. The Topical Corticosteroid Phobia questionnaire for professionals (TOPICOP-P) was used to measure attitudes toward topical corticosteroids (TCSs). Higher scores reflect a more negative attitude. Results: A total of 407 HCPs (124 GPs, 33 YHPs, 51 pediatricians, 56 dermatologists, 58 pharmacists, and 85 pharmacy assistants) participated. Compared to dermatologists, other HCPs showed greater reluctance to TCS. This difference was highlighted by the finding that half of GPs reported to prescribed only TCS of mild potency for infants with severe AD, while few dermatologists (9%) reported a similar approach. Dermatologists had lowest TOPICOP-P scores (median: 19, IQR: 12–28). GPs and pharmacy assistants had highest scores (GPs median: 36, IQR: 31–44, pharmacy assistants: median: 36, IQR: 31–42). More corticophobia was significantly associated with prescription of a lower TC potency class in prescribing HCPs (B −0.04, 95% CI: −0.07 to 0.01, p = 0.01), and a trend was found between more corticophobia and longer perceived durability of one TCS tube. Conclusions: This study shows the differences in management of AD and reluctance toward TCS in HCPs. Furthermore, corticophobia among HCPs and its influence on the selection of TCS potency class and recommendations were demonstrated. To reduce corticophobia and improve care for AD, more education is needed.

Effective atopic eczema (AE) control not only improves quality of life but may also prevent the atopic march. The Royal College of General Practitioners’ (RCGP) curriculum does not currently provide specific learning outcomes on AE management. We aimed to gain consensus on learning outcomes to inform curriculum development. A modified Delphi method was used with questionnaires distributed to gather the views of a range of health care professionals (HCPs) including general practitioners (GPs), dermatologists, dermatology nurses and parents of children with AE attending a dedicated paediatric dermatology clinic. Ninety-one questionnaires were distributed to 61 HCPs and 30 parents; 81 were returned. All agreed that learning should focus on the common clinical features, complications and management of AE and the need to appreciate its psychosocial impact. Areas of divergence included knowledge of alternative therapies. Parents felt GPs should better understand how to identify, manage and refer severe AD and recognized the value of the specialist eczema nurse. Dermatologists and parents highlighted inconsistencies in advice regarding topical steroids. This study identifies important areas for inclusion as learning outcomes on AE management in the RCGP curriculum and highlights the importance of patients and parents as a valuable resource in the development of medical education.

Atopic dermatitis (AD) is one of the most common skin disorders in Europe.1 In the United States, most healthcare visits for AD occur with primary care physicians (PCPs), with fewer visits to dermatologists.2 Data on the care pathway patterns in AD patients in France are lacking. In the era of biologics, characterizing the care trajectories of patients and their satisfaction with their disease management are essential to design future patterns for correct referrals and prescriptions. In this context, the aim of our study was to assess the current care pathway and patient satisfaction with AD management in France. The French Eczema Association sent an online survey in 2022 to AD patients over 18 years old with questions regarding symptoms, visited physicians and satisfaction regarding their AD management. The severity of AD was assessed via the Patient-Oriented Eczema Measure (POEM) score.3 Treatment satisfaction (TS) was defined as the proportion of patients who declared being satisfied with their AD management. In total, 1251 patients with AD responded to the survey, of whom 455 (36%) with an additional dermatosis were excluded. Therefore, 796 patients were included in the study. Characteristics of patients are represented in Table 1. The types of healthcare professionals consulted are represented in Table 2. Among the patients consulting a hospital-based dermatologist, 24.2% consulted on their own [27.3% mild AD (MAD) and 22.7% moderate-to-severe AD (MSAD) patients], 50% were referred by a general physician and 25.8% by a dermatologist in private practice (22.7% of MAD and 27.3% of MSAD). The referral purpose was to improve management in 62% of cases (50% of MAD and 67.7% of MSAD) and to change treatments in 32% of cases (43.8% of MAD and 26.5% of MSAD). The mean number of consultations per year with a general physician was 4 ± 2.4, 2.1 ± 2 with a hospital dermatologist and 1.8 ± 1 with a private dermatologist. For patients who declared to have been doctor shopping (n = 501), 54.3% of them declared that it was the dermatologist who prescribed the suitable treatment: hospital dermatologist in 10.8% (7.5% MAD vs. MSAD 13.4%) and private dermatologist in 43.5% (45.1% MAD vs. 42.2% MSAD) of cases. On the contrary, 36.4% of these patients declared that it was the general physician that prescribed the suitable treatment (40.4% MAD vs. 32.2% MSAD). The general satisfaction of AD management is represented in Table 2. In the United States, the most visited physician by AD patients is the general practitioner. This is explained by a long-standing relationship between patients and their PCPs, as well as a shortage of dermatologists in France.4 Some studies have suggested that PCPs lack confidence in the diagnosis and management of skin disease.5 In fact, dermatology placements are not frequent in junior doctor rotations, and as such, the bulk of dermatology learning takes place in-practice during the postgraduate term.6 Therefore, skin disease remains a learning need for PCPs, and it is paramount to ensure that PCPs are able to manage AD within the scope of their practices. For both, MAD and MSAD, the visited dermatologists are mostly those in private practice rather than those in hospitals. For those who have been doctor shopping, the type of visited physician has an impact on MAD and MSAD patients' satisfaction. For MAD, satisfaction is highest with private dermatologists. Surprisingly, for MSAD, it is highest with PCPs. While MSAD patients' needs seem to be met upon consulting PCPs, it is important to highlight that with a breadth of management options available, more complex or problematic AD should seek a specialist's opinion for optimal results. Exploring the AD care pathway and patients' satisfaction in France should promote the reinforcement of PCPs' skills in diagnosing and treating this condition. In France as in the United States, PCPs are allowed to prescribe systemic immunosuppressants7 but have a high level of discomfort in doing so in real-life practice. Initiation of systemic immunosuppressants by PCPs can be validated by teledermatologists through tele-expertise, and renewal can subsequently be done under joint supervision. Given the shortfall in dermatology workforce, pathway schemes in atopic dermatitis can rest on the efficacy of teledermatology8-10 in designing these models. Finally, European clinical practice guidelines for referral patterns can help optimize patients' access to new biologics when needed. The authors would like to thank Dr Marketa Saint Aroman (Foundation Eczema Pierre Fabre), Dr Claire Thenié (Sanofi) and Dr Jean Michel Joubert (Almirall) for their support in the implementation of this project. Almirall, Fondation Eczema Pierre Fabre, Sanofi. None. Data can be provided for valid scientific noncommercial purposes.

Topical corticosteroids (TCS) are regarded as the mainstay treatment for atopic dermatitis (AD). As AD has a tendency to heal naturally, the long-term efficacy of TCS in AD management should be compared with the outcomes seen in patients with AD not using TCS. However, there are few long-term studies that consider patients with AD not using TCS. We designed a prospective multicenter cohort study to assess the clinical outcomes in patients with AD who did not use TCS for 6 months and then compared our results with an earlier study by Furue et al which considered AD patients using TCS over 6 months. Our patients’ clinical improvement was comparable with the patients described in Furue’s research. In light of this, it is reasonable for physicians to manage AD patients who decline TCS, as the expected long-term prognosis is similar whether they use TCS or not.

A growth in the incidence rate for atopic dermatitis (AD) in infants has been observed for this decade. Early formation of AD (at the age of 3-6 months) is observed in 45% of infants, and in 60% of infants - during the first year of life. As many as 65% of children (by the age of 7) and 74% of children (by the age of 16) suffering from AD have a spontaneous remission of the disease. As many as 20-43% of children suffering from AD further develop bronchial asthma, and the incidence rate of allergic rhinitis is twice as high. In spite of the fact that topical corticosteroids (TCS) are prescribed frequently enough, there is a need in the non-hormonal therapy due to poor compliance with the TCS treatment regimen in connection with side effects. Treatment of AD is often complicated by the colonization with Staphylococcus aureus and inefficacy of the external therapy with topical corticosteroids because many patients with AD have a high level of IgE against the superantigen of Staphylococcus. 1% pimecrolimus cream (PIM) and TCS were compared in a long-term large-scale study involving younger children suffering from mild to moderate AD. Materials and methods. The five-year open-label study involved 2,418 children, who were randomized into groups receiving PIM (n = 1205; in case of an aggravation - short-term administration of TCS) or TCS (n = 1213). The main goal of the study was to compare the safety of these two methods of treatment; an auxiliary goal was to confirm the long-term efficacy of PIM. Treatment was considered to be successful if the score based on the IGA scale was 0 (clean skin) or 1 (almost clean). Results. The effect in both groups of the drugs - PIM and TCS - was fast, and the success of treatment was recorded for >50% of patients by Week 3. In both groups, treatment was determined to be successful after 5 years in >85% of patients, and treatment of manifestations of AD on the face was efficient in 95% of all subjects. In the PIM group, the need in steroids was considerably lower than in the TCS group (7 days of administration vs. 178 days in the TCS group). In both groups, there were adverse events similar by their nature and frequency, and no disorders of humoral or cellular immunity were revealed. Conclusions. The long-term administration of PIM in case of mild to moderate AD in children was revealed to be safe and had no effect on the immune system. When PIM was used, the need in corticosteroids was considerably reduced (steroid-preserving effect). These data confirm that PIM is as efficient as TCS and can be used as the first-line therapy for mild to moderate AD in infants and younger children.