Quantitative analysis of topical treatments in atopic dermatitis: unexpectedly low use of emollients and strong correlation of topical corticosteroid use both with depression and concurrent asthma

Abstract

Summary Background Despite decades of use, the actual amounts of topical corticosteroids (TCS) and emollients used in moderate‐to‐severe atopic dermatitis (AD) under real‐world conditions are unknown. Thus, it remains unclear whether inadequate use is widespread. Objectives To quantify the use of TCS and emollients in moderate‐to‐severe AD. Methods Double‐blinded drug prescribing was recorded prospectively at the point of drug dispensing within a catchment area of approximately 450 000 people over a 31‐year period in a population‐based cohort marked by failure of disease control in primary care (n = 844). For each patient, prescribing was recorded over a 12‐month period in order to minimize fluctuations. Results This approach resulted in a near‐complete dataset, which was essentially free of reporting bias and recording bias. Atopic comorbidities matched expected frequencies. Median use of TCS was statistically significantly higher in juvenile patients (age < 16 years) compared with adult patients (49·2 vs. 38·1 g per month), in male vs. female patients (46·8 vs. 29·7 g per month) and in patients receiving concurrent asthma treatment (40·4 vs. 26·7 g per month). TCS use was strongly associated with antidepressant treatment. Emollient use was unexpectedly low with a median of 9·6 g per day (range 1·4–30·1). Results were replicated in an independent validation cohort. Conclusions Deficient use of emollients may be a factor contributing to AD severity. Our analysis showed that the use of TCS does not exceed current guidelines. Accurate quantification of topical treatments provides a widely accessible strategy to measure the real‐world impact of novel AD treatments. What's already known about this topic? Both emollient and topical corticosteroid (TCS) use have been a mainstay of atopic dermatitis (AD) treatment for over 60 years. The actual quantities used by patients under real‐world conditions are unknown. What does this study add? The real‐world use of emollients is fourfold lower than the amount recommended in current guidelines. Underuse of emollients may be a significant factor in disease exacerbation. The use of TCS is significantly higher in male patients and is higher in patients with AD who also have asthma. The use of TCS is strongly associated with concurrent antidepressant treatment.

Narrowband ultraviolet B phototherapy is associated with a reduction in topical corticosteroid and clinical improvement in atopic dermatitis: a historical inception cohort study

“…Nonetheless, the availability of quantitative monthly data on TCS dispensed makes it likely that mean BSA involvement exceeded 10% at baseline across the cohort, as detailed previously. 11 This inference was further supported by measurement of EASI in an explorative patient group at baseline, which yielded a mean AE SD score of 22 AE 12 (n = 6). In addition, the presence of continued active AD in this patient cohort is further supported by the fact that significant time elapsed between primary care referral and (i) initial dermatology review (range 2-10 weeks), (ii) initiation of phototherapy (2-8 weeks) and (iii) completion of the first 10 courses of treatment (range 1-89 treatments per course).…”

“…Patient selection, assembly of cohort, data refinement and quality checks have been described in detail prevously. 11 Definition of observational window, cohort refinement and validation are detailed in Data S1. The overall design was a nonplacebo-controlled before-versus-after treatment analysis as detailed in Results below.…”

“…Using these resources, we previously reported on the clinical characteristics of patients with AD not controlled in primary care, along with the amounts of topical corticosteroids (TCS) and emollients dispensed to these patients. 11 Randomized controlled trials commonly report outcomes for AD treatments, using instruments such as the Eczema Area and Severity Index (EASI) and SCORing Atopic Dermatitis (SCORAD), in a blinded manner. By contrast, in routine clinical care, outcome monitoring is aimed at establishing if a perceived benefit would justify potential future repeat treatment for a given patient.…”

Overcoming poor adherence is a major hurdle to managing atopic dermatitis

“…Choi et al . greatly extend our understanding of the atopic dermatitis adherence hurdle in a large, well‐designed, population‐based study of AD prescribing patterns . This observational cohort study included patients with moderate‐to‐severe AD seen by a dermatologist in Scotland's National Health Service from 1986 to 2017.…”

“…However, Choi et al . have clearly demonstrated that steroid phobia is not the only (or perhaps the most important) hurdle to AD treatment success, with their critically important and novel finding that patients with AD are not using prescribed emollients either, with only about one‐third to one‐eighth of the recommended amount being used . The findings of Choi et al .…”