Atopic Dermatitis in US Adults: From Population to Health Care Utilization

Atopic Dermatitis: A Disorder of both Adults and Children with Varying Longitudinal Course

The longitudinal course of atopic dermatitis (AD) is heterogeneous and complex. While previously thought to be a childhood disorder, recent studies demonstrated that childhood-onset AD may take several different courses that may involve persistence into adulthood becoming a lifelong condition. Other patients only demonstrated adult-onset AD. Different factors may play a role in the timing of AD onset. Assessing the longitudinal course also involves understanding the changing temporal pattern of AD. Understanding the dynamic course of AD is important in identifying individualized treatment recommendations for patients.

Tapinarof validates the aryl hydrocarbon receptor as a therapeutic target: A clinical review

The aryl hydrocarbon receptor (AhR) is a ligand-dependent transcription factor that has wide-ranging roles, including regulation of inflammation and homeostasis. AhR is not a cell surface receptor; rather, it exists in a cytoplasmic complex that responds to a wide variety of structurally dissimilar endogenous, microbial, and environmental ligands. The ubiquitous expression of AhR, its ability to be activated by a wide range of ligands, and its capacity to act as a master regulator for gene expression and homeostasis make it a promising new therapeutic target. Clinical trials of tapinarof cream have now validated AhR agonism as a therapeutic approach that can deliver significant efficacy for treating inflammatory skin diseases, including psoriasis and atopic dermatitis. Tapinarof 1% cream is a first-in-class, nonsteroidal, topical, AhR agonist with a pharmacokinetic profile that results in localized exposure at sites of disease, avoiding systemic safety concerns, drug interactions, or off-target effects. Psoriasis and atopic dermatitis both involve epidermal inflammation, cellular immune responses, dysregulation of skin barrier protein expression, and oxidative stress. On the basis of the clinical effectiveness of tapinarof cream for treating inflammatory skin diseases, we review how targeting AhR may offer a significant opportunity in other conditions that share key aspects of pathogenesis, including asthma, inflammatory bowel disease, eosinophilic esophagitis, ophthalmic, and nervous system diseases.

ItchyQoL reveals differences in itch symptom experience in routine dermatologic care

Itch is a common symptom of dermatologic diseases associated with significant impairment of health-related quality of life (QoL). This study reveals disparities in itch symptom experience and itch impact on QoL. A retrospective study of patient-reported outcome measure (PRO) data (ItchyQoL, Itch NRS, Pain Interference, Anxiety) for 387 outpatient dermatology visits to characterize the impact of itch on patients' QoL and itch symptom experience based on skin color in patients with dermatologic disease. Most patients were Caucasian females (67%) with mean age of 48 years. Correlative analyses showed mild itch associated with emotional impacts on QoL (p < 0.01), while severe itch associated with functional and emotional impacts on QoL (p < 0.01). African American (AA) patients reported more "severe-range" answers for 15 (68%) ItchyQoL items and had higher ItchyQoL mean scores (p = 0.001). ItchyQoL demonstrated an emotional impact on QoL by mild itch, but a functional and emotional impact on QoL by severe itch. Further, AAs suffered from greater itch-related impairment in QoL than Caucasian patients, especially due to scarring and sleeplessness.

Real-World Clinical, Psychosocial and Financial Burden of Atopic Dermatitis: Results from the Spanish Cohort of the MEASURE-AD Trial

BACKGROUND

Atopic dermatitis (AD) is one of the most prevalent skin diseases, but there are numerous knowledge gaps surrounding the impact this disease has on quality of life (QoL), mental health, and out-of-pocket expenses involved in the management of AD. The available scientific evidence on the multidimensional burden of AD is usually based on studies with measures reported by patients themselves.

METHODS

In this context, the MEASURE-AD trial was developed as a cross-sectional, multicenter, multinational trial using patient- and physician-reported measures to characterize the multidimensional burden of AD in adults with moderate-to-severe AD.

RESULTS

This paper presents the results of the Spanish cohort. We found that Spanish adults with moderate-to-severe AD and high EASI score (21.1-72) had a significantly increased disease burden, high severity of symptoms such as itch and sleep disturbances, impaired mental health and QoL, higher use of health care resources, and more out-of-pocket expenses than patients with low EASI scores (0-7 or 7.1-21).

CONCLUSIONS

This study provides information to better understand disease burden, and identify aspects to be improved in the management of AD.

Rural Health Disparities in Allergy, Asthma, and Immunologic Diseases: The Current State and Future Direction for Clinical Care and Research

Rural health disparities are well documented and continue to jeopardize the long-term health and wellness for the millions of individuals who live in rural America. The disparities observed between urban and rural residents encompass numerous morbidity and mortality measures for several chronic diseases and have been referred to as the "rural mortality penalty." Although the unmet health needs of rural communities are widely acknowledged, little is known about rural health disparities in allergies, asthma, and immunologic diseases. Furthermore, the intersection between rural health disparities and social determinants of health has not been fully explored. To achieve a more complete understanding of the factors that perpetuate rural health disparities, greater research efforts followed by improved practice and policy are needed that account for the complex social context within rural communities rather than a general comparison between urban and rural environments or focusing on biomedical factors. Moreover, research efforts must prioritize community inclusion throughout rural areas through meaningful engagement of stakeholders in both clinical care and research. In this review, we examine the scope of health disparities in the rural United States and the impact of social determinants of health. We then detail the current state of rural health disparities in the field of allergy, asthma, and immunology. To close, we offer future considerations to address knowledge gaps and unmet needs for both clinical care and research in addressing rural health disparities.

Trends in Health Care Utilization Among United States Children With Eczema by Age, Sex, Race, and Hispanic Ethnicity: National Health Interview Survey 2006-2018

Background: Higher health care utilization has been proven among US children with eczema than those without, but disparities may exist among sociodemographic subgroups. Objective: To determine health care utilization trends among children with eczema across sociodemographic factors. Methods: We included children (0-17 years old) from the US National Health Interview Survey 2006-2018. We calculated the survey-weighted health care utilization by determining proportion of children attending a well-child checkup, seen by a medical specialist, and seen by a mental health professional in the previous 12 months for children with and without eczema, by race (white, black, American Indian/Alaska Native, Asian, and multiracial), Hispanic ethnicity (yes/no), age (0-5, 6-10, 11-17), and gender (male/female) subgroups using SPSS complex samples. Joinpoint regression was used to estimate piecewise log-linear trends in the survey-weighted prevalence, annual percentage change, and disparities between subgroups. Results: We included 149,379 children-there was higher health care utilization in children with eczema than those without. However, when comparing the average annual percentage change (AAPC), white children had a significantly higher AAPC of "attending a well-child checkup" than black children. In addition, only white children showed a significantly increasing trend in being "seen by a medical specialist," whereas all other minority race subgroups had stagnant trends. For those "seen by a mental health professional," there were increasing trends only in the male and non-Hispanic subgroups out of all the sociodemographic subgroups. Conclusion: Improving awareness among primary care physicians to refer children with moderate-to-severe eczema to medical specialists (eg, allergists, dermatologists, and mental health/attention-deficit/hyperactivity disorder professionals) when necessary could improve quality of life and reduce emergency department visits-especially among minority race, Hispanic, and female children.

Impact of a Digital Atopic Dermatitis Educational Intervention on Hispanic Patients and Family Members

With the increasing incidence of atopic dermatitis (AD) in the U.S., the highest prevalence of AD being found in Hispanic countries, and the rising Hispanic-American population, educational resources on eczema focused on Spanish-speaking populations are needed more than ever. As such, the primary goal of this project was to assess the beneficial impact of an educational intervention conducted through a virtual platform for Hispanic individuals living with atopic dermatitis. Utilizing WhatsApp, the study enrolled 55 participants diagnosed with AD and/or parents of children diagnosed with AD. Participants were enrolled in a seven-day educational module with daily topics on AD health knowledge. A health knowledge survey was administered before the educational program, upon completion of the program, and one month after completion. The program found a 14% increase in AD health knowledge upon completion of the program (p < 0.001). Most importantly, there was no significant difference found between the health knowledge survey submitted at program completion and one month after completion, signaling that health knowledge taught through the course was successfully retained by participants (p = 0.29). Qualitative themes involving atopic disease were additionally explored through group discussions, including mental health and peer stigma. This study is the first of its kind in dermatology utilizing the WhatsApp format. The success of retained health knowledge regarding AD demonstrates that future virtual endeavors can be effective and accessible methods of patient education overall for populations that might not have ease of access to major medical centers.

Epidemiology of adult patients with atopic dermatitis in AWARE 1: A second international survey

Background

There are gaps in our understanding of the epidemiology of atopic dermatitis (AD) in adults.

Objective

To evaluate the prevalence and severity of AD in adults from countries/regions within Asia, Eurasia, Latin America, Middle East, and Russia.

Methods

This international, web-based survey was performed in Argentina, Brazil, China, Colombia, Egypt, Hong Kong, Israel, Malaysia, Mexico, Russia, Kingdom of Saudi Arabia (KSA), Singapore, Taiwan, Thailand, Turkey, and United Arab Emirates. Questionnaires were sent to adult members of online respondent panels for determination of AD and assessment of severity. A diagnosis of AD required respondents to meet the modified United Kingdom (UK) Working Party criteria and to self-report they had a physician diagnosis of AD. Severity of AD was determined using Patient-Oriented Scoring of Atopic Dermatitis (PO-SCORAD), Patient-Oriented Eczema Measure (POEM), and Patient Global Assessment (PGA).

Results

Among respondents by country/region the prevalence of AD ranged from 3.4% in Israel to 33.7% in Thailand. The prevalence was generally higher in females versus males. Severity varied by scale, although regardless of scale the proportion of respondents with mild and moderate disease was higher than severe disease. PGA consistently resulted in the lowest proportion of severe AD (range 2.4% China - 10.8% Turkey) relative to PO-SCORAD (range 13.4% China - 41.6% KSA) and POEM (range 5.1% China - 16.6% Israel).

Conclusions

This survey highlights the importance of AD in adults, with high prevalence and high morbidity among respondents and emphasizes that AD is not just a disease of childhood-there is disease persistence and chronicity in adults.

Proposed solutions by the American College of Allergy, Asthma, and Immunology and advocacy experts to address racial disparities in atopic dermatitis and food allergy

Atopic dermatitis (AD) and food allergies are more prevalent and more severe in people with skin of color than White individuals. The American College of Allergy, Asthma, and Immunology (ACAAI) sought to understand the effects of racial disparities among patients with skin of color with AD and food allergies. The ACAAI surveyed its members (N = 200 completed), conducted interviews with health care providers and advocacy leaders, and hosted a roundtable to explore the challenges of diagnosis and management of AD and food allergies in people with skin of color and to discuss potential solutions. Most of the survey respondents (68%) agreed that racial disparities make it difficult for people with skin of color to receive adequate treatment for AD and food allergies. The interviews and roundtable identified access to care, burden of costs, policies and infrastructure that limit access to safe foods and patient education, and inadequate research involving people with skin of color as obstacles to care. Proposed solutions included identifying ways to recruit more people with skin of color into clinical trials and medical school, educating health care providers about diagnosis and treating AD and food allergy in people with skin of color, improving access to safe foods, creating and disseminating culturally appropriate materials for patients, and working toward longer appointment times for patients who need them. Challenges in AD and food allergy in persons with skin of color were identified by the ACAAI members. Solutions to these challenges were proposed to inspire actions to mitigate racial disparities in AD and food allergy.

A combination of HLA-DP α and β chain polymorphisms paired with a SNP in the DPB1 3' UTR region, denoting expression levels, are associated with atopic dermatitis

Introduction: Components of the immune response have previously been associated with the pathophysiology of atopic dermatitis (AD), specifically the Human Leukocyte Antigen (HLA) Class II region via genome-wide association studies, however the exact elements have not been identified. Methods: This study examines the genetic variation of HLA Class II genes using next generation sequencing (NGS) and evaluates the resultant amino acids, with particular attention on binding site residues, for associations with AD. The Genetics of AD cohort was used to evaluate HLA Class II allelic variation on 464 subjects with AD and 384 controls. Results: Statistically significant associations with HLA-DP α and β alleles and specific amino acids were found, some conferring susceptibility to AD and others with a protective effect. Evaluation of polymorphic residues in DP binding pockets revealed the critical role of P1 and P6 (P1: α31M + (β84G or β84V) [protection]; α31Q + β84D [susceptibility] and P6: α11A + β11G [protection]) and were replicated with a national cohort of children consisting of 424 AD subjects. Independently, AD susceptibility-associated residues were associated with the G polymorphism of SNP rs9277534 in the 3' UTR of the HLA-DPB1 gene, denoting higher expression of these HLA-DP alleles, while protection-associated residues were associated with the A polymorphism, denoting lower expression. Discussion: These findings lay the foundation for evaluating non-self-antigens suspected to be associated with AD as they potentially interact with particular HLA Class II subcomponents, forming a complex involved in the pathophysiology of AD. It is possible that a combination of structural HLA-DP components and levels of expression of these components contribute to AD pathophysiology.

Iatrogenic Burden of Atopic Dermatitis

ABSTRACT

The management required for atopic dermatitis (AD) may worsen patient burden, thereby resulting in iatrogenic burden, that is, morbidity caused by medical treatment. We sought to describe the iatrogenic burden of AD and conducted a narrative review of key areas that clinicians can address to minimize it. Clinicians should think strategically about itch trigger avoidance, encourage slow incorporation of lifestyle changes, and emphasize step-up therapy when avoidance becomes too burdensome. Out-of-pocket treatment costs should be incorporated into shared decision making to balance affordability, preference, efficacy, and safety. Polypharmacy should be minimized by eliminating ineffective, nonevidence-based, and redundant therapies while appropriately stepping up to advanced therapy. Clinicians should take adequate time to communicate, the impact of AD on quality of life, and incorporate evidence-based guidelines. The multidimensional nature of AD requires a dynamic approach. Future guidelines should incorporate step-up, step-down, and maintenance approaches to reduce treatment burden and improve quality of life.

Adults with concomitant atopic dermatitis and asthma have more frequent urgent health care utilization and less frequent scheduled follow-up visits than adults with atopic dermatitis or asthma only: A nationwide cohort study

BACKGROUND

Atopic dermatitis (AD) and asthma often co-occur in the same patient, and health care utilization is related to disease severity of these diseases.

OBJECTIVE

To investigate differences in healthcare utilization in adults with concomitant AD and asthma compared to patients with asthma or AD only.

METHODS

All Danish adults with a hospital-diagnosis of AD, asthma or concomitant AD and asthma recorded in national registries were included. Health care utilization data were obtained in 3-month intervals from two year prior to index date (the date of the first hospital diagnosis), and to five years after.

RESULTS

A total of 12,409 patients with AD were included (11,590 with AD only and 819 with concomitant AD and asthma), and 65,539 with asthma only. Adults with concomitant AD and asthma had higher risk of hospitalization for AD (OR 1.38, 95% CI (1.15-1.67), p=0.001) and asthma (OR 1.16, 95% CI (1.00-1.35), p=0.047) compared to patients with only AD and asthma, respectively. These patients also had fewer visits in outpatient clinics for AD (OR 0.10, 95% CI (0.08-0.12), p<0.001) and asthma (OR 0.34, 95% CI (0.29-0.39), P<0.001) compared to patients with only AD or asthma. Outpatient clinic visits for rhinitis were more frequent among patients with concomitant AD and asthma compared to patients with only AD or asthma.

CONCLUSION

Adults with concomitant AD and asthma had different patterns of healthcare utilization compared to adults with AD or asthma alone, suggesting that improvements in management and monitoring may reduce unscheduled health care visits, and lower healthcare costs.

Evaluating the Longitudinal Course of Atopic Dermatitis: Implications for Clinical Practice

Atopic dermatitis (AD) is characterized by a heterogenous longitudinal course with varying severity, flares, and persistence. However, AD course is not routinely assessed in clinical practice or controlled trials. Our objective was to review the longitudinal course of AD in children and adults and discuss implications for routine practice and clinical trials. We conducted a focused review of the published literature, including retrospective, prospective, and interventional studies, clinical trials, and consensus guidelines. Estimates of AD persistence varied widely across studies but suggested that AD can indeed persist through childhood and into adulthood. Predictors of persistence are broad and include both disease-intrinsic and disease-extrinsic (i.e., environmental) factors. In real-world practice, most individuals with AD experience fluctuations in the signs and symptoms over time and do not experience persistent clearance of skin lesions. Clinical trials use mainly static measurements that do not take into account fluctuations in course, which may confound treatment effects. The heterogenous temporal pattern of AD can be incorporated into routine practice to better set expectations and offer a realistic prognosis. AD course should be routinely incorporated into clinical decision making. Future studies are needed to develop a standardized approach to AD assessment and treatment that includes longitudinal course.

Predictors of nonresponse to dupilumab in patients with atopic dermatitis: A machine learning analysis

BACKGROUND

Many patients with atopic dermatitis (AD) have a suboptimal response to systemic therapy.

OBJECTIVE

This study assessed predictors of nonresponse to dupilumab in patients with AD.

METHODS

Data (April 2017 through June 2019) for patients aged ≥12 years with AD (ICD-9/10-CM: 691.8/L20.x) who initiated dupilumab on or after April 1, 2017 (index date) were collected from an electronic health record and insurance claims database. Nonresponse indicators (dupilumab discontinuation, addition of another systemic therapy or phototherapy, addition of a high-potency topical corticosteroid, AD-related hospital visit, AD-related emergency room visit, incident skin infection) were predicted from available demographic and clinical variables using machine learning.

RESULTS

Among 419 patients (mean age: 45 years), 145 (35%) experienced ≥1 indicator of nonresponse in the 6-month post-index period. In patients with ≥1 indicator, the most common was dupilumab discontinuation (47% [68/145]). Of note, this analysis could not capture nonmedical reasons of dupilumab discontinuation (eg, cost, access). The most common predictors of nonresponse were a claim for ibuprofen (in 69% of patients with a nonresponse indicator) and Quan-Charlson Comorbidity Index value of 3-4 (59%).

CONCLUSION

Systemic dupilumab therapy for AD can be associated with a relatively high prevalence of nonresponse indicators. Factors associated with these indicators -ie, predictors of nonresponse- may be used to optimize disease management.

Efficacy and Safety of Baricitinib in Combination With Topical Corticosteroids in Patients With Moderate-to-Severe Atopic Dermatitis With Inadequate Response, Intolerance, or Contraindication to Cyclosporine: Results From a Randomized, Placebo-Controlled, Phase III Clinical Trial (BREEZE-AD4)

BACKGROUND

Baricitinib, an oral selective Janus Kinase (JAK) 1 and JAK 2 inhibitor, was shown to improve the signs and symptoms of moderate-to-severe atopic dermatitis (AD).

OBJECTIVES

Evaluate the efficacy and safety of baricitinib with background topical corticosteroids (TCS) in patients with moderate-to-severe AD and inadequate response, intolerance, or contraindication to cyclosporine A (CyA).

METHODS

In this double-blind, randomized, placebo-controlled, Phase III study, patients were randomized 1:1:2:1 to placebo (N=93), baricitinib 1-mg (N=93), 2-mg (N=185), or 4-mg (N=92) with background TCS. The primary endpoint was the proportion of patients receiving baricitinib 4-mg or 2-mg (+ TCS) versus placebo + TCS who achieved ≥75% improvement from baseline in the Eczema Area and Severity Index (EASI 75) at Week 16.

RESULTS

Baricitinib 4-mg + TCS was superior to placebo + TCS for EASI 75 (4-mg: 32%, placebo: 17%, p=0.031) at Week 16 and for improvements in itch, skin pain, and number of night-time awakenings due to itch. Improvements were maintained through 52 weeks of treatment. Treatment-emergent adverse events (TEAEs) were more common with baricitinib than placebo (+ TCS); most were mild or moderate. The most frequent TEAEs with baricitinib 4-mg + TCS were nasopharyngitis, herpes simplex, influenza, and headache. No deaths or deep vein thromboses were reported.

CONCLUSIONS

Baricitinib 4-mg + TCS improved the signs and symptoms of moderate-to-severe AD through 52 weeks of treatment in patients with inadequate response, intolerance, or contraindication to CyA. The safety profile was consistent with previous studies of baricitinib in moderate-to-severe AD.

Determinants of costs and benefits in atopic dermatitis routine care in Germany

BACKGROUND AND OBJECTIVES

The economic burden of atopic dermatitis (AD) is of particular interest. The present study aims to analyse the association of disease-related characteristics, annual costs and treatment benefits in AD.

METHODS

Between August 2017 and June 2019, a cross-sectional observational study in patients with AD was conducted in Germany. Cost-of-illness data were assessed from the societal perspective. Disease characteristics included severity, time since diagnosis, therapy, as well as atopic comorbidity and the implementation of prevention measures. Subgroup analyses of the total costs were conducted for these characteristics. A linear regression model was applied to analyse the impact of disease characteristics on the costs. Furthermore, associations of biologic treatment with outcome parameters were analysed.

RESULTS

1,291 patients from 111 centres were included in the analyses. The total costs amounted on average to € 3,660 ± € 6,428 per patient and year. Higher costs were shown in various patient groups, for example in patients using biologics (€ 20,983 vs. € 2,470). In a regression analysis, gender, education, and the number of implemented prevention measures were identified as significant predictors of costs. Patients treated with biologics showed consistently better outcome parameters and were more often satisfied with their treatment.

CONCLUSIONS

Gender, education, and implemented prevention measures are significant cost determinants in AD. The results confirm that treatment with biologics is the main cost driver in AD. However, incremental patient-relevant benefits of high-priced therapy are reflected by the significantly better clinical outcomes in the group treated with biologics.

Impact of Social Determinants on the Burden of Asthma and Eczema: Results from a US Patient Survey

Introduction

Little is known about how patients with asthma and eczema perceive their medical care and burden of disease. A survey was conducted to evaluate the perceptions among the general patient population with asthma and/or eczema regarding disease and treatment burden and barriers to adequate care.

Methods

An online survey was completed by market research panelists in the USA between March 24, 2020 and April 6, 2020. Eligible participants were at least 18 years of age and endorsed a diagnosis of asthma and/or eczema. Survey responses are described for all participants, by designated racial/ethnic groups, and by income level.

Results

In all, 841 participants completed the survey (asthma, n = 554; eczema, n = 398; both, n = 111; White, n = 421; Black, n = 252; Hispanic, n = 95; low income [less than $15,000/year], n = 99; higher income [at least $15,000/year], n = 713). More Black and Hispanic participants than White participants, and more participants with low income than higher income, endorsed health literacy as a barrier (e.g., filling out official documents, understanding written materials). Participants with low income were less likely than participants with higher income to have an asthma action plan (42% vs 53%, respectively) and to discuss asthma control with their healthcare provider (54% vs 69%). Black and Hispanic participants were more likely than White participants to have an emergency department visit (52% and 49% vs 31%, respectively) or hospitalization (31% and 39% vs 16%) for asthma within the last 12 months. Participants reporting low income indicated that they experienced eczema symptoms more frequently than participants with higher income; 35% of low-income participants vs 15% of higher-income participants reported that they had not tried any eczema treatments. Participants in all racial/ethnic and income-level groups reported that their asthma or eczema impacted their lifestyle and daily activities.

Conclusion

More effective and culturally informed communication and education strategies to improve health information uptake and shared decision-making are needed to reduce the burdens of disease and treatment in highly impacted populations.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12325-021-02021-0.

Disparities in asthma and eczema outcomes have been described in various populations. However, little is known about how these patient populations perceive their disease management or disease burden. A survey of 841 adults across diverse demographic groups in the USA with asthma and/or eczema was conducted to evaluate overall perceived disease burden and to specifically understand burden experiences by marginalized populations. In general, all participants indicated that asthma and eczema have a negative physical, emotional, and social impact on their lives. Some participants who identified as Black or Hispanic, and those with low income (less than $15,000/year), indicated greater difficulties in filling out paperwork or understanding written materials related to their condition than White participants or those with higher incomes. Black and Hispanic participants tended to receive asthma care in the emergency department or urgent care more than White participants and had more emergency department visits and hospitalizations than White Participants. Participants with low income were less likely to discuss their asthma management with their doctor than those with higher incomes and also indicated potential undertreatment of eczema. These results indicate that Black, Hispanic, or low-income patients may experience barriers to health equity. These barriers include lack of effective communication methods and materials to meet the needs of all patients, as well as the overall lack of quality healthcare access. These challenges must be addressed to overcome social disparities in health.

Financial Burden of Atopic Dermatitis Out-of-Pocket Health Care Expenses in the United States

Background

Atopic dermatitis (AD) is associated with considerable financial cost. However, the full burden of out-of-pocket (OOP) expenses is not well understood.

Objective

We sought to characterize the OOP health care expenses associated with AD management.

Methods

A 25-question voluntary online survey was administered to National Eczema Association members worldwide (n = 113,502). Inclusion criteria (US residents age ≥18 years who either self-reported had AD or were primary caregivers of individuals with AD) were met by 77.3% (1118/1447) of respondents.

Results

Respondents reported OOP expenses in 3 categories: (1) health care providers and prescriptions, including health care provider visit deductibles (68.7% [686]), prescription co-pays (64.3% [635]), and prescriptions not covered by insurance (48.6% [468]); (2) nonprescription health care products, including moisturizers (94.3% [934]), hygiene products (85.0% [824], allergy medications (75.1% [715]), itch relievers (68.25% [647]), dietary supplements (52.2% [491]), and sleep aids (37.0% [336]); and (3) complementary approaches, including cleaning products (74.7% [732]), clothing/bedding (44.8% [430]), alternative medications (19.0% [180]), and adjunctive therapies (15.9% [150]). The median annual AD OOP expense was US $600 (range, US $0–$200,000), with 41.9% (364) reporting expenditures US $1000 or greater.

Conclusions

Out-of-pocket expenses place a significant financial burden on individuals with AD. Additional studies are needed to better understand associations and impact of OOP costs.

Financial burden and impact of atopic dermatitis out-of-pocket healthcare expenses among black individuals in the United States

Black race is associated with increased atopic dermatitis (AD) severity and healthcare resource utilization. However, the burden of out-of-pocket (OOP) expenses among black individuals with AD is not well understood. We sought to characterize the categories and impact of OOP healthcare expenses associated with AD management among black individuals. A 25-question voluntary online survey was administered to National Eczema Association members (N = 113,502). Inclusion criteria (US residents age ≥ 18 years; self-report of AD or primary caregivers of individuals with AD) was met by 77.3% (1118/1447) of respondents. Black individuals with AD were younger, had lower household income, Medicaid, urban residence, poor AD control and frequent skin infections (P ≤ 0.02). Blacks vs. non-blacks reported more OOP costs for prescription medications covered (74.2% vs. 63.6%, P = 0.04) and not covered (65.1% vs. 46.5%, P = 0.0004) by insurance, emergency room visits (22.1% vs. 11.8%, P = 0.005), and outpatient laboratory testing (33.3% vs. 21.8%, P = 0.01). Black race was associated with increased household financial impact from OOP expenses (P = 0.0009), and predictors of financial impact included minimally controlled AD (adjusted OR [95% CI] 13.88 [1.63-117.96], P = 0.02), systemic therapy (4.34 [1.63-11.54], 0.003), > $200 monthly OOP expenses (14.28 [3.42-59.60], P = 0.0003), and Medicaid (4.02 [1.15-14.07], P = 0.03). Blacks with Medicaid had higher odds of harmful financial impact (3.32 [1.77-6.24], P = 0.0002) than those of black race (1.81 [1.04-3.15], P = 0.04) or with Medicaid (1.39 [1.02-1.88], P = 0.04) alone. Black race is associated with increased OOP costs for AD and significant household financial impact. Targeted interventions are needed to address financial disparities in AD.

Retrospective analysis of adverse events with dupilumab reported to the United States Food and Drug Administration

BACKGROUND

Atopic dermatitis (AD) is one of the most common inflammatory skin diseases and has aesthetic, physical, and emotional-social sequelae when left untreated.

OBJECTIVE

To classify the most common adverse reactions associated with dupilumab treatment in patients with AD.

METHODS

The United States Food and Drug Administration Adverse Event Reporting (FAERS) database was analyzed for common adverse reactions associated with dupilumab, topical pimecrolimus, and topical tacrolimus. Phase III clinical trial data were used to compare the rate of herpes infections between the treatment group and placebo group.

RESULTS

The most common adverse reaction associated with dupilumab was ocular complications. Herpes infections were extremely rare in the patients with AD being treated with dupilumab.

LIMITATIONS

Prescribing information for dupilumab, topical pimecrolimus, and topical tacrolimus is not available. Adverse effects are reported by patients, health care providers, and pharmaceutical companies, they have not been corroborated.

CONCLUSIONS

Ocular complications are the most common complication associated with dupilumab. The rate of herpes infection is low in patients being treated with dupilumab, topical pimecrolimus, and topical tacrolimus. There is no significant difference for the rate of herpes infection between, placebo, dupilumab, topical pimecrolimus, and the topical tacrolimus treatment group, suggesting that dupilumab does not affect herpes infection rates.

The efficacy of Janus kinase inhibitors in patients with atopic dermatitis: A systematic review and network meta-analysis

Janus kinase (JAK) inhibitors are novel treatment approaches for atopic dermatitis (AD). This study was aimed to compare the efficacy of JAK inhibitors for AD treatment. The database of PubMed, EMBASE, Web of Science, and Cochrane Library were searched until March 28, 2021, for randomized control trials (RCTs) of AD patients treated with JAK inhibitors. Baseline and follow-up data were extracted. Efficacy of JAK inhibitors was evaluated using 50% improvement in Eczema Area and Severity Index (EASI-50). A Bayesian multiple treatment network meta-analysis with fixed effects was performed. Odds ratio (OR) with 95% credibility interval (CrI) were used for comparing the efficacy of JAK inhibitors with placebo for AD. A total of seven RCTs of JAK inhibitors with 2530 patients were included for analysis. After excluded one study with high risk of bias, a total of six JAK inhibitors with 17 different formulations and doses were analyzed. The severity of atopic dermatitis of included patients was almost moderate to severe (93.4%). Compared with placebo, all JAK inhibitors had higher EASI-50 at 4 weeks of treatment, except for baricitinib with 1 mg once daily (QD) (OR: 1.4, 95% Crl: 0.9-2.1), ruxolitinib with 0.15% QD (OR: 2.3, 95% Crl: 0.8-11.4), and ruxolitinib with 0.5% QD (OR: 3.4, 95% Crl: 0.9-18.1). Among all included, upadacitinib had the highest probability of being the best treatment (SUCRA value of 0.936). In topical JAK inhibitors, delgocitinib 3% twice a day (BID) had the highest probability of being the best treatment (SUCRA value of 0.849). JAK inhibitors had promising treatment efficacy for AD patients. Upadacitinib with 30 mg QD had the best efficacy among all included JAK inhibitors, and delgocitinib 3% BID showed superior efficacy over other topical JAK inhibitors for AD treatment.

Human leukocyte antigen class-I variation is associated with atopic dermatitis: A case-control study

Atopic dermatitis (AD) is a common immune-medicated skin disease. Previous studies have explored the relationship between Human Leukocyte Antigen (HLA) allelic variation and AD with conflicting results. The aim was to examine HLA Class I genetic variation, specifically peptide binding groove variation, and associations with AD. A case-control study was designed to evaluate HLA class I allelic variation and binding pocket polymorphisms, using next generation sequencing on 464 subjects with AD and 388 without AD. Logistic regression was used to evaluate associations with AD by estimating odds ratios (95% confidence intervals). Significant associations were noted with susceptibility to AD (B*53:01) and protection from AD (A*01:01, A*02:01, B*07:02 and C*07:02). Evaluation of polymorphic residues in Class I binding pockets revealed six amino acid residues conferring protection against AD: A9F (HLA-A, position 9, phenylalanine) [pocket B/C], A97I [pocket C/E], A152V [pocket E], A156R [pocket D/E], B163E [pocket A] and C116S [pocket F]. These findings demonstrate that specific HLA class I components are associated with susceptibility or protection from AD. Individual amino acid residues are relevant to protection from AD and set the foundation for evaluating potential HLA Class I molecules in complex with peptides/antigens that may initiate or interfere with T-cell responses.

Baricitinib Rapidly Improves Skin Pain Resulting in Improved Quality of Life for Patients with Atopic Dermatitis: Analyses from BREEZE-AD1, 2, and 7

Introduction

Skin pain (described as discomfort or soreness) is increasingly recognized as a symptom of atopic dermatitis which impacts patient quality of life. This analysis examined the effect of baricitinib on skin pain in atopic dermatitis in three phase 3 studies (BREEZE-AD1, -AD2, and -AD7).

Methods

Patients were randomly assigned 2:1:1:1 to receive once-daily placebo, baricitinib 1 mg, 2 mg, or 4 mg in BREEZE-AD1 (N = 624) and -AD2 (N = 615) and 1:1:1 to receive once-daily placebo, baricitinib 2 mg, or 4 mg, with topical corticosteroids, in BREEZE-AD7 (N = 329) for 16 weeks. Patients recorded their skin pain severity using the Skin Pain Numerical Rating Scale (NRS) via an electronic daily diary. Data were analyzed by study as least squares mean change from baseline in daily scores for the randomly assigned patients using mixed model repeated measures analysis. Analysis of Skin Pain NRS response was done using logistic regression using non-responder imputation.

Results

Baricitinib produced significant percentage change from baseline compared with placebo in patient-reported skin pain severity by day 2 in BREEZE-AD1 (baricitinib 4 mg − 11.9%, p < 0.001; baricitinib 2 mg − 6.4%, p = 0.016; baricitinib 1 mg − 6.2%, p = 0.016), -AD2 (baricitinib 4 mg − 12.6%, p < 0.001; baricitinib 2 mg − 5.6%, p = 0.036; baricitinib 1 mg − 6.9%, p = 0.011), and -AD7 (baricitinib 4 mg − 6.9%, p = 0.04; baricitinib 2 mg − 7.9%, p = 0.018). A greater proportion of patients treated with baricitinib reported at least a 4-point reduction in Skin Pain NRS score at week 16 (Skin Pain NRS responders) in BREEZE-AD1 (baricitinib 4 mg 25.3%, p < 0.001), -AD2 (baricitinib 4 mg 20.0%, p < 0.001; baricitinib 2 mg 19.0%, p < 0.001), and -AD7 (baricitinib 4 mg 48.8%, p < 0.001; baricitinib 2 mg 45.2%, p = 0.004) compared to placebo. A significantly higher proportion of Skin Pain NRS responders also achieved at least a 4-point improvement in Dermatology Life Quality Index at week 16 when compared with Skin Pain NRS non-responders in BREEZE-AD1 (89.2%, p < 0.0001), -AD2 (92.5%, p < 0.0001), and -AD7 (88.3%, p < 0.0001).

Conclusion

Baricitinib improved patient-reported skin pain severity as early as day 2.

ClinicalTrials.gov identifiers

BREEZE-AD1, NCT03334396; BREEZE-AD2, NCT03334422; BREEZE-AD7, NCT03733301.

Predictors and age-dependent pattern of psychologic problems in childhood atopic dermatitis

BACKGROUND/OBJECTIVES

Little is known about the predictors and trends of psychological comorbidities in childhood atopic dermatitis (AD), or whether they occur in an age-dependent pattern. We hypothesized racial/ethnic and socioeconomic disparities lead to increased psychological problems among children with AD and psychological comorbidities occur in an age-dependent manner.

METHODS

We analyzed cross-sectional data on 228 898 children aged 2-17 years from the 1997-2018 National Health Interview Survey.

RESULTS

Children with AD had higher proportions of depression/sadness (17.2% vs 12.6%; odds ratio [95% confidence interval]: 1.44 [1.37-1.51]), attention deficit (hyperactivity) disorder (ADD/ADHD) (10.0% vs 7.1%; 1.46 [1.38-1.55]), emotional/behavioral difficulties (29.9% vs 23.5%; 1.77 [1.69-1.84]), feelings of frequent worry (38.8% vs 23.5%; 1.66 [1.58-1.74]), and autism (1.9% vs 0.9%; 2.00 [1.75-2.29]). Among children with AD, psychologic comorbidity was associated with atopic comorbidities and multimorbidity and white race, households with lower income and education, and no insurance coverage. In children with or without AD, the prevalence of autism peaked during pre-adolescence; ADD/ADHD and emotional/behavioral difficulties peaked in adolescence; and depression/sadness and feelings of frequent worry increased steadily throughout childhood without plateau.

CONCLUSION

Atopic dermatitis was associated with multiple psychologic disorders, particularly among those with atopic comorbidities, white race, and low household income. Psychologic comorbidities increased in an age-dependent pattern, though similar to children without AD.

HLA Class I Polymorphisms Influencing Both Peptide Binding and KIR Interactions Are Associated with Remission among Children with Atopic Dermatitis: A Longitudinal Study

Atopic dermatitis (AD) is a disease of immune dysregulation and skin barrier dysfunction with a relapsing, remitting course and has been associated with several different genetic risk variants. HLA represent a highly variable set of genes that code for cell surface protein molecules involved in the Ag-specific immune response, including the regulation or functioning of T cells, NK cells, and APCs. The purpose of this study was to evaluate associations between HLA class I polymorphisms and the progression of AD over time. We evaluated the associations of AD symptoms and HLA class I polymorphisms based on high-resolution two-field typing in a longitudinal cohort of children with AD (up to 10 y of follow-up). Seven hundred and ninety-two children were evaluated every 6 mo, resulting in 12,752 AD evaluations. Using generalized estimating equations and corrected p values, B*44:02 was found to be associated with AD remission (1.83 [1.35, 2.47]; p = 0.0015). The HLA-B residues at position 116 (d-aspartate) and 80 (T-threonine) were associated with remission (1.42 [1.13, 1.76], p = 0.003; corrected p = 0.028) and (1.45 [1.17, 1.80], p = 0.0008; corrected p = 0.0024), respectively. B80T is a killer-cell Ig-like receptor (KIR) site. Our findings reveal that two axes of immune response (T cell and NK cell) may influence disease progression. Identifying binding pocket changes in addition to other factors (e.g., allergens) that increase the risk or severity of AD can improve our understanding of the immunologic mechanisms associated with AD and may lead to personalized therapies for improving patient care.

Itch and Sleep Improvements with Baricitinib in Patients with Atopic Dermatitis: A Post Hoc Analysis of 3 Phase 3 Studies

Introduction

Burdensome symptoms of atopic dermatitis include itch and sleep disturbance. This post hoc analysis reports the effect of baricitinib on itch and sleep disturbance during the first week of treatment in 3 phase 3 studies.

Methods

Patients were randomized 2:1:1:1 to once-daily placebo or baricitinib 1 mg, 2 mg, or 4 mg in the BREEZE-AD1 and -AD2 studies and 1:1:1 to once-daily placebo or baricitinib 2 mg or 4 mg in the BREEZE-AD7 study. Topical corticosteroids were only allowed in BREEZE-AD7. Patients completed the itch numerical rating scale and atopic dermatitis sleep scale (ADSS) items 1–3 using an electronic daily diary. Data were analyzed by study as least squares mean percent change from baseline in daily scores for the randomized patients. Mixed model repeated measures analysis was used to analyze change from baseline values.

Results

A total of 624, 615, and 329 patients were randomized in BREEZE-AD1, -AD2, and -AD7, respectively. Itch severity significantly improved with baricitinib 2 mg and 4 mg versus placebo starting at day 2 (1 day after first dose) in BREEZE-AD1 and -AD7 and at day 1 in BREEZE-AD2. Patients’ ability to fall asleep (ADSS item 1) significantly improved with baricitinib 2 mg and 4 mg versus placebo starting at day 2 in all three studies. There were significant improvements in patients waking due to itch (ADSS item 2) with baricitinib 4 mg versus placebo starting at day 2 in all three studies. Patients’ ability to return to sleep after being woken by itch (ADSS item 3) was significantly improved with baricitinib 4 mg versus placebo starting at day 2 in BREEZE-AD1 and -AD2 and at day 4 in BREEZE-AD7.

Conclusion

Rapid onset of action, typically 1 day after taking the first dose of baricitinib, was observed consistently for the burdensome symptoms of itch and sleep disturbance.

ClinicalTrials.gov identifiers

BREEZE-AD1, NCT03334396; BREEZE-AD2, NCT03334422; BREEZE-AD7, NCT03733301.

Designing responsive dressings for inflammatory skin disorders; encapsulating antioxidant nanoparticles into biocompatible electrospun fibres

Inflammatory skin disorders are highly prevalent and current treatments are marred by side-effects. Here, we have designed anti-inflammatory fibrous sheets with the potential to treat low exudate inflammatory skin disorders such as psoriasis or atopic dermatitis. Antioxidant and anti-inflammatory nanoparticles composed of crosslinked poly(propylene sulfide) (PPS) were encapsulated in poly(ethylene oxide) (PEO) fibres via electrospinning from an aqueous suspension. The loading of nanoparticles did not adversely effect the homogenous nature of the electrospun fibres; furthermore, nanoparticles retained their morphology, size and anti-inflammatory character after electrospinning. The PPS-nanoparticle-loaded nanofibres were found to be highly cytocompatible when tested on human dermal fibroblasts. These findings suggest they have significant potential to topically treat inflamed tissues that are characterized by high reactive oxygen species (ROS) levels.

Prevalence and Trend of Allergen Sensitization in Adults and Children with Atopic Dermatitis Referred for Patch Testing, North American Contact Dermatitis Group Data, 2001-2016

BACKGROUND

The association between atopic dermatitis (AD) and allergic contact dermatitis (ACD) is controversial.

OBJECTIVE

To analyze the prevalence, reaction strength, and trends of the most commonly positive and relevant allergens in patients with AD referred for patch testing.

METHODS

This was a retrospective analysis of 38,482 patients from the North American Contact Dermatitis Group, 2001 to 2016.

RESULTS

Most adults (56.0%) and children (52.8%) with a history of AD had a final diagnosis of ACD. Adults (66.5% vs 65.6%; χ², P = .1459) and children (61.4% vs 62.3%, P = .7074) with or without a history of AD had similar proportions of one or more allergic patch test reactions. Adults with a history of AD had a greater number of allergic patch test positive reactions than those without it (2.0 ± 2.4 vs 1.9 ± 2.3; t test, P < .0001), whereas children did not (1.5 ± 1.8 vs 1.4 ± 1.6; P = .3839). Nickel sulfate, methylisothiazolinone, formaldehyde, fragrance mix I, sodium gold thiosulfate, and thimerosal were the most common allergens in adults and children with a history of AD. In multivariable logistic regression models, adults with versus without a history of AD had increased odds of reacting to 10 of the top 25 North American Contact Dermatitis Group screening allergens. Most allergens had similar strengths of reaction in adults or children with and without a history of AD or a current AD diagnosis; cobalt, fragrance mix I, and propylene glycol had weaker reactions. In multivariable logistic regression, adults with versus without an AD history had increased odds of relevance for 10 of the 25 most currently relevant allergens, whereas children with an AD history did not have increased relevance for any specific allergens.

CONCLUSIONS

Most patients referred for patch testing with AD history had a final diagnosis of ACD. Patients with AD history had a similar likelihood of having a positive patch test reaction as those without an AD history. Adults with an AD history had a higher number of positive patch test reactions.

Atopic Dermatitis Is Associated With Lower Patient Satisfaction in US Adults

BACKGROUND

Atopic dermatitis (AD) is complex with unmet needs and management challenges in clinical practice. Little is known about patient satisfaction among adults with AD.

OBJECTIVE

The aim of the study was to determine patterns and predictors of patient satisfaction among adults with AD.

METHODS

Data were analyzed from the 2000-2015 Medical Expenditure Panel Survey. Patient satisfaction was assessed by the Consumer Assessment of Healthcare Providers and Systems survey.

RESULTS

Atopic dermatitis (linear regression; adjusted β [95% confidence interval {95% CI}] = -0.75 [-1.25 to -0.25]) was associated with lower patient satisfaction compared with no AD. Adults with 1 or more office-based visits had increased odds of high satisfaction (>75th percentile; logistic regression; adjusted odds ratio [95% CI] = 1.81 [1.30-2.52]). Adults who saw an outpatient dermatologist or allergist had lower satisfaction (adjusted β [95% CI] = -0.65 [-1.27 to -0.03]). Patient satisfaction among adults with AD was associated with older age (adjusted β [95% CI] = 40-59 years, 1.85 [0.90-2.80]; ≥60 years, 6.13 [5.18-7.09]) and inversely associated with lower income (-1.82 [-2.68 to -0.96]) or middle income (-0.85 [-1.59 to -0.12]), race/ethnicity (Hispanic, -1.40 [-2.42 to -0.38]; other/multiracial, -2.34 [-3.53 to -1.15]), public (-4.50 [-6.43 to -2.58]) or no insurance (-4.53 [-6.47 to -2.59]), and multimorbidity (-0.48 [-0.61 to -0.35]).

CONCLUSIONS

Adults with AD in the United States had decreased patient satisfaction, particularly those with lower income, fewer outpatient visits, and multimorbidity. There are substantial unmet needs in patient satisfaction for AD.

Reliability and Longitudinal Course of Itch/Scratch Severity in Adults With Atopic Dermatitis

BACKGROUND

Itch is a complex and burdensome symptom in atopic dermatitis (AD). Severity of scratching/excoriation (SCORAD-scratch) has been found to be a valid measure of itch in AD. However, little is known about the longitudinal course of scratching/excoriations in AD.

METHODS

A prospective, dermatology practice-based study was performed of adults with AD (N = 399). The patients were assessed at baseline and approximately 6, 12, 18, and 24 months.

RESULTS

Severity of excoriations correlated best with the Numerical Rating Scale-worst itch (Spearman correlation, ρ = 0.50), followed by a Patient-Reported Outcome Measurement Information System Itch Questionnaire-scratching behavior T score (ρ = 0.48), Numerical Rating Scale-average itch (ρ = 0.41), relative frequency of itch (ρ = 0.36), and frequency of itch from eczema (ρ = 0.29, all P < 0.0001). Scratching severity showed good reliability (intraclass correlation coefficient range = 0.62-0.69). Overall, 30.6% and 5.5% had moderate (2) or severe (3) SCORAD-scratch scores. Among patients with baseline moderate (2) or severe (3) SCORAD-scratch scores, 18.9% and 13.6% continued to have moderate or severe scores at 1 or more follow-up visits. In repeated-measures regression models, persistent SCORAD-scratch scores were associated with baseline severity of excoriations (adjusted β [95% confidence interval] = 0.51 [0.37 to 0.65]), Medicaid insurance (-0.35 [-0.65 to -0.04]), and Eczema Area and Severity Index scores (0.03 [0.02 to 0.04]).

CONCLUSIONS

Adult AD patients had a heterogeneous longitudinal course with fluctuating severity of excoriations.

Mental Health Symptoms and Functional Impairment in Children With Atopic Dermatitis

BACKGROUND

The impact of childhood atopic dermatitis (AD) on social and behavioral issues is not well understood.

OBJECTIVE

This study sought to determine the prevalence and predictors of social and behavioral symptoms and functional impairment among US children with AD.

METHODS

The 1996 to 2015 Medical Expenditure Panel Surveys were analyzed, including a representative, cross-sectional study of 2553 US children with AD. Behavioral and functional issues were examined using Columbia Impairment Scale (CIS) scores.

RESULTS

Childhood AD was associated with behavioral and functional problems, particularly nervousness (odds ratio [OR], 1.18; 95% confidence interval [95% CI], 1.06-1.31), home behavior (OR, 1.18; 95% CI, 1.06-1.32), staying out of trouble (OR, 1.18; 95% confidence interval, 1.06-1.31), and relationships with other kids (OR, 1.17; 95% CI, 1.05-1.31) and with siblings (OR, 1.14; 95% CI, 1.02-1.28). Higher CIS scores were present in children with AD versus without AD (adjusted β, 0.62; 95% CI, 0.22-1.02) and with psoriasis (adjusted β, 0.86; 95% CI, 0.22-1.49). Among children with AD, higher CIS scores were notably associated with male sex, older age, lower household income, public insurance, and comorbid depression and anxiety.

CONCLUSIONS

AD was associated with behavioral and functional impairment, similar to psoriasis and other common chronic conditions. There are significant sociodemographic differences in CIS scores.

Efficacy and Safety of Baricitinib Combined With Topical Corticosteroids for Treatment of Moderate to Severe Atopic Dermatitis: A Randomized Clinical Trial

Importance

Baricitinib, an oral selective Janus kinase 1 and 2 inhibitor, effectively reduced disease severity in moderate to severe atopic dermatitis (AD) in 2 phase 3 monotherapy studies.

Objective

To assess the efficacy and safety of 4 mg and 2 mg of baricitinib in combination with background topical corticosteroid (TCS) therapy in adults with moderate to severe AD who previously had an inadequate response to TCS therapy.

Design, Setting, and Participants

This double-blind, placebo-controlled, phase 3 randomized clinical trial, BREEZE-AD7 (Study of Baricitinib [LY3009104] in Combination With Topical Corticosteroids in Adults With Moderate to Severe Atopic Dermatitis) was conducted from November 16, 2018, to August 22, 2019, at 68 centers across 10 countries in Asia, Australia, Europe, and South America. Patients 18 years or older with moderate to severe AD and an inadequate response to TCSs were included. After completing the study, patients were followed up for up to 4 weeks or enrolled in a long-term extension study.

Interventions

Patients were randomly assigned (1:1:1) to receive 2 mg of baricitinib once daily (n = 109), 4 mg of baricitinib once daily (n = 111), or placebo (n = 109) for 16 weeks. The use of low-to-moderate potency TCSs was allowed.

Main Outcomes and Measures

The primary end point was the proportion of patients achieving a validated Investigator Global Assessment for Atopic Dermatitis (vIGA-AD) score of 0 (clear) or 1 (almost clear), with a 2-point or greater improvement from baseline at week 16.

Results

Among 329 patients (mean [SD] age, 33.8 [12.4] years; 216 [66%] male), at week 16, a vIGA-AD score of 0 (clear) or 1 (almost clear) was achieved by 34 patients (31%) receiving 4 mg of baricitinib and 26 (24%) receiving 2 mg of baricitinib compared with 16 (15%) receiving placebo (odds ratio vs placebo, 2.8 [95% CI, 1.4-5.6]; P = .004 for the 4-mg group; 1.9 [95% CI, 0.9-3.9]; P = .08 for the 2-mg group). Treatment-emergent adverse events were reported in 64 of 111 patients (58%) in the 4-mg group, 61 of 109 patients (56%) in the 2-mg group, and 41 of 108 patients (38%) in the placebo group. Serious adverse events were reported in 4 patients (4%) in the 4-mg group, 2 (2%) in the 2-mg group, and 4 (4%) in the placebo group. The most common adverse events were nasopharyngitis, upper respiratory tract infections, and folliculitis.

Conclusions and Relevance

A dose of 4 mg of baricitinib in combination with background TCS therapy significantly improved the signs and symptoms of moderate to severe AD, with a safety profile consistent with previous studies of baricitinib in AD.

Trial Registration

ClinicalTrials.gov Identifier: NCT03733301.

Burden and socioeconomics of asthma, allergic rhinitis, atopic dermatitis and food allergy

INTRODUCTION

Asthma, allergic rhinitis, atopic dermatitis, and food allergy affect approximately 20% of the global population. Few studies describe the burden of the totality of these diseases and only a handful studies provide a comprehensive overview of the socioeconomic impact of these diseases.

AREAS COVERED

For this narrative review, we searched Pubmed using selected keywords and inspected relevant references using a snowballing process. We provide an overview of the socioeconomic burden of allergic diseases (in particular, asthma, allergic rhinitis, atopic dermatitis, and food allergy). The focus of this review is on their epidemiology (incidence, prevalence), burden (disability-adjusted life years, quality of life), and direct and indirect costs (absenteeism and presenteeism). We have put special emphasis on differences between countries.

EXPERT COMMENTARY

Both the prevalence and the burden of allergic diseases are considerable with prevalence varying between 1% and 20%. We identified a plethora of studies on asthma, but studies were generally difficult to compare due to the heterogeneity in measures used. There were only few studies on the burden of food allergy; therefore, more studies on this allergy are required. For future studies, we recommend standardizing epidemiologic, socioeconomic impact, and quality of life measures of allergic diseases.

A real-world study of the longitudinal course of adult atopic dermatitis severity in clinical practice

BACKGROUND

Little is known about the longitudinal course of adult atopic dermatitis (AD) lesional severity and extent in clinical practice.

OBJECTIVE

To determine the longitudinal course of AD in clinical practice.

METHODS

A prospective, dermatology practice-based study was performed (n = 400). Patients were assessed at baseline and approximately 6, 12, 18, and 24 months by eczema area and severity index (EASI) and objective-scoring atopic dermatitis (objective-SCORAD). Multivariable repeated measures linear regression models were constructed to evaluate AD severity over time.

RESULTS

Overall, 36.2% and 18.2% of patients had moderate (6.0-22.9) or severe (23.0-72.0) EASI scores at any visit, respectively. Similarly, 29.0% and 26.4% of patients had moderate (24.0-37.9) or severe (38.0-83.0) objective-SCORAD scores at any visit, respectively. Among patients with baseline moderate (6.0-22.9) or severe (23.0-72.0) EASI scores, 25.0% and 18.6% continued to have moderate or severe scores at 1 or more follow-up visits, respectively. Similarly, among patients with baseline moderate (24.0-37.9) or severe (38.0-83.0) objective-SCORAD scores, 22.6% and 24.5% continued to have moderate or severe scores at 1 or more follow-up visits, respectively. In longitudinal regression models, EASI was significantly associated with body surface area (adjusted β [95% confidence interval]: 0.16 [0.09-0.23]) and edema/papulation (2.31 [0.19-4.43]). In addition, objective-SCORAD was significantly associated with body surface area (0.12 [0.04-0.21]), edema/papulation (4.69 [2.05-7.32]), and scratch (3.34 [0.45-6.24]) over time.

CONCLUSION

AD lesional severity has a heterogeneous longitudinal course. Many patients had fluctuating lesional severity scores over time. A minority of patients had persistently moderate or severe lesions over time. Most patients with moderate-severe disease at baseline were unable to achieve persistent lesional clearance.

Baricitinib in patients with moderate-to-severe atopic dermatitis and inadequate response to topical corticosteroids: results from two randomized monotherapy phase III trials

BACKGROUND

Baricitinib, an oral selective Janus kinase 1 and 2 inhibitor, effectively reduced atopic dermatitis (AD) severity in a phase II study with concomitant topical corticosteroids.

OBJECTIVES

To evaluate the efficacy and safety of baricitinib in patients with moderate-to-severe AD who had an inadequate response to topical therapies.

METHODS

In two independent, multicentre, double-blind, phase III monotherapy trials, BREEZE-AD1 and BREEZE-AD2, adults with moderate-to-severe AD were randomized 2 : 1 : 1 : 1 to once-daily placebo, baricitinib 1 mg, 2 mg, or 4 mg for 16 weeks.

RESULTS

At week 16, more patients achieved the primary end point of Validated Investigator's Global Assessment of AD (0, 1) on baricitinib 4 mg and 2 mg compared with placebo in BREEZE-AD1 [N = 624; baricitinib 4 mg 16·8% (P < 0·001), 2 mg 11·4% (P < 0·05), 1 mg 11·8% (P < 0·05), placebo 4·8%], and BREEZE-AD2 [N = 615; baricitinib 4 mg 13·8% (P = 0·001), 2 mg 10·6% (P < 0·05), 1 mg 8·8% (P = 0·085), placebo 4·5%]. Improvement in itch was achieved as early as week 1 for 4 mg and week 2 for 2 mg. Improvements in night-time awakenings, skin pain and quality-of-life measures were observed by week 1 for both 4 mg and 2 mg (P ≤ 0·05, all comparisons). The most common adverse events in patients treated with baricitinib were nasopharyngitis and headache. No cardiovascular events, venous thromboembolism, gastrointestinal perforation, significant haematological changes, or death were observed with any baricitinib dosage.

CONCLUSIONS

Baricitinib improved clinical signs and symptoms in patients with moderate-to-severe AD within 16 weeks of treatment and induced rapid reduction of itch. The safety profile remained consistent with prior findings from baricitinib clinical development in AD, with no new safety concerns.

The Journal of Allergy and Clinical Immunology: In Practice 2019 Highlights

This article provides highlights of the clinically impactful original studies and reviews published in The Journal of Allergy and Clinical Immunology: In Practice in 2019 on the subjects of anaphylaxis, asthma, dermatitis, drug allergy, food allergy, immunodeficiency, immunotherapy, rhinitis/sinusitis, and urticaria/angioedema/mast cell disorders. Within each topic, practical aspects of diagnosis and management are emphasized. Treatments discussed include lifestyle modifications, allergen avoidance therapy, positive and negative effects of pharmacologic therapy, and various forms of immunologic and desensitization management. We designed this review to help readers consolidate and use this extensive and practical knowledge for the benefit of their patients.

Racial/Ethnic Variation in Use of Ambulatory and Emergency Care for Atopic Dermatitis among US Children

Previous studies indicate racial/ethnic differences in health care utilization for pediatric atopic dermatitis (AD), but do not account for disease severity impact. We sought to examine the relationship between race/ethnicity and health care utilization, both overall and by specific visit type, while accounting for AD control. A longitudinal cohort study of children with AD in the United States was performed to evaluate the association between race/ethnicity and health care utilization for AD. AD control and health care utilization were assessed biannually. Our study included 7,522 children (34.2% white, 54.2% black, and 11.5% Hispanic) who were followed for a median of 4 years (interquartile range 0.9-8.4 years). After adjusting for sociodemographic and other factors, black and Hispanic children were up to nearly threefold more likely than white children to receive medical care for AD across almost all levels of AD control. Black and Hispanic children had higher odds of primary care and emergency visits compared to whites. Black children with poorly controlled AD were significantly less likely to see a dermatologist than white children with similarly poorly controlled AD (odds ratio = 0.74, 95% confidence interval = 0.64-0.85 for limited control; odds ratio = 0.59, 95% confidence interval = 0.47-0.76 for uncontrolled AD). Together, these findings suggest the presence of racial/ethnic disparities in health care utilization for AD.