Treatment of moderate-to-severe atopic eczema in adults within the U.K.: results of a national survey of dermatologists

Abstract

SummaryBackgroundLittle is known about U.K. dermatologists' treatment approaches towards adult patients with recalcitrant moderate‐to‐severe atopic eczema.ObjectivesWe wanted to learn about (i) treatment approaches used for this disease in the U.K.; (ii) factors that influence treatment decisions and (iii) perceived gaps in evidence on treatment safety and efficacy, and priorities for future trials.MethodsWe conducted an online survey of consultant‐level dermatologists in the U.K.ResultsSixty‐one respondents from over 30 centres reported on management of moderate‐to‐severe atopic eczema in adults, outwith the context of an acute flare. Phototherapy or psoralen–ultraviolet A was the most common therapeutic modality chosen first line (46%), and this was usually narrowband ultraviolet B. Systemic therapy was chosen as a first‐line approach by 36% of dermatologists. Azathioprine was the commonest drug reported being used as first line followed by oral corticosteroids, ciclosporin and methotrexate. Methotrexate was the most common second‐line treatment of respondents. The key factors that influenced decision making on the use of phototherapy and systemic agents were the respondent's clinical experience, results of baseline tests (systemic agents) and knowledge of both efficacy and acute and chronic side‐effect profiles. The most important evidence gaps identified were the relative effectiveness of treatments, the alternatives to current approaches and the safety of long‐term maintenance treatment. With regard to future trials, respondents suggested that priority should be given to studies involving methotrexate.ConclusionsWhile survey study designs have limitations, we found that phototherapy, in particular narrowband ultraviolet B, was respondents' preferred first‐line treatment for adults with recalcitrant moderate‐to‐severe atopic eczema, perhaps reflecting access to, and clinical experience of, this approach. Azathioprine is widely used as a longer‐term maintenance treatment.

Use of systemic corticosteroids for atopic dermatitis: International Eczema Council consensus statement

“…Baseline data from a German registry of moderate‐to‐severe AD revealed that 13% of participants had been on systemic CS in the 3 months prior to enrollment, and in another German study, 10% of patients with AD had used systemic CS over 2 years . In a survey of 61 U.K. consultant dermatologists, 42% listed systemic CS as their first‐line systemic agent for adult moderate‐to‐severe AD . In surveys of European and North American paediatric dermatologists, oral CS were the first‐line systemic agents for severe paediatric AD for 31% and 5% of respondents, respectively …”

Translating translation into patient benefit for atopic eczema

“…In line with the concept of pharmacogenetic dosing, almost 95% of respondents from our 2013 survey agreed/strongly agreed that TPMT level at baseline should guide choice of initial dose. These data are consistent with an earlier survey of UK consultant which showed a high level of uptake of TPMT enzyme‐level testing by dermatologists (94%), compared with gastroenterologists (60%) and rheumatologists (47%), prior to prescribing azathioprine …”

“…The evidence from this study and a placebo‐controlled cross over trial of azathioprine, also conducted in the UK, has underpinned recommendations in UK and European guidelines on disease treatment, and azathioprine is now in widespread use in the UK. For example, evidence from a 2013 survey of UK dermatologists conducted through the UK Translational Research Network in Dermatology (UK TREND) and the UK Dermatology Clinical Trials Network (UK DCTN), indicated that azathioprine has been widely adopted in the UK as a treatment of refractory atopic eczema . Systemic therapy was the most popular second‐line treatment option, chosen by 49% of respondents, and it was also the second most popular first‐line treatment option (after phototherapy), chosen by 36% of respondents.…”

Perspectives of online surveys in dermatology

“…As shown, survey studies showed great ability to recruit a high number of participants for dermatology studies in a manner bypassing geographical borders. In contrast, non‐web‐based surveys included significantly fewer participants on average …”