Atopic dermatitis in adults: An Australian management consensus

Quality of Care and Management of Atopic Dermatitis Across Different Levels of Healthcare-A Survey-Based Patient Experience

Atopic dermatitis (AD) is a chronic and fluctuating disease. Optimal management of AD and related comorbidities requires seamless coordination across multiple layers of the healthcare system. The objective of this survey was to explore patients' experiences with current management of AD. Out of 251 responders to this anonymous survey, 76% reported to have moderate or severe AD. Sixty-nine percent with moderate and 45% with severe AD were followed up at primary care level only. Use of advanced systemic treatment options was rare, and the majority experienced itch (97%), dry skin, rash, negative impact on self-esteem and comorbidities despite ongoing treatment. Only 36% received a treatment plan, more often in secondary (78.3%) than primary care (25.0%). Forty-three percent did not know who was responsible for their follow-up and 54% felt no one was responsible. Treatment options were commonly not known or understood. The survey results demonstrate undertreatment, lack of a holistic approach for management of AD. A national pathway including clear referral criteria and timelines can streamline management of AD across multiple levels of the healthcare system.

Barriers to the introduction of novel advanced targeted treatments for Australian dermatology patients: Are skin diseases symptomatic of a systemic healthcare problem?

The aim of this article is to provide education to clinicians about certain barriers restricting the use of advanced targeted treatments in Australian health care. For illustrative purposes, the article focuses on dermatological conditions, but the content is relevant to all specialties that treat inflammatory and chronic diseases. Barriers to care discussed result in a lower than necessary standard of care for patients in Australia despite important advancements in medicine.

[Algoritmo de tratamiento de la dermatitis atópica en Perú. Consenso de expertos]

Objective

Atopic dermatitis is a chronic, systemic, relapsing disease with dermatological manifestations, which imposes a high burden on patients, families and the health care system and has a high psychological, social, and economic impact and on the quality of life of patients. It mainly affects the pediatric population and, to a lesser extent, the adult population. The clinical presentation varies according to the age and evolution of the disease, and currently there are multiple pharmacological and non-pharmacological therapies available for the symptomatic management of patients.

Methods

To present an algorithm for the management of atopic dermatitis, proposed as a series of recommendations on the management, diagnosis, education, and follow-up of these patients.

Results

A consensus was reached using the nominal group technique. The methodology was developed in 7 phases, including: posing the research questions, literature search, an initial proposal of recommendations, elaboration of the final recommendations and the management algorithm with three voting cycles, consensus was established with 80% favorability.

Conclusions

The result of the consensus process is a management algorithm for patients with mild, moderate/severe atopic dermatitis derived from expert recommendations. The algorithm establishes diagnostic and treatment criteria and provides updated recommendations, including all therapeutic alternatives available in Peru for the management of patients with mild, moderate, and severe atopic dermatitis.

Consensus of Spanish Society of Hospital Pharmacy on optimal medication therapy management of atopic dermatitis

AIM

This study's aims are: 1) To use the Delphi method to determine the level of consensus among HPs as regards the factors involved in the current approach to patients with AD; 2) To identify potential areas for improvement in hospital pharmacy in terms of dealing with patients with severe AD; and 3) To contribute to adequate pharmaceutical care for patients with AD by drawing up recommendations.

METHODS

A two-round Delphi survey with participation from HPs from all over Spain. Three theme-based blocks were set out: 1) AD; 2) Management of patients with severe AD in the Hospital Pharmacy setting; and 3) Unmet needs (pathology, patient, treatment and management).

RESULTS

The 42 HPs participating reached a consensus in recognizing the impact of severe AD on the patients suffering from it, the need to encourage adherence and the recommendations to use scales that take into account the patient's quality of life and indicators of the patient's experience. It has also been demonstrated that it is worthwhile evaluating the results in real clinical practice in consensus with other specialists from the multidisciplinary team. Finally, it is advisable to use drugs that have demonstrated long-term effectiveness and safety for patients with severe AD, given the disease´s chronic nature.

CONCLUSIONS

This Delphi consensus highlights the impact of severe AD on patients, the importance of a multidisciplinary and holistic approach, in which HP play a major role. It also highlights the importance of increased access to new drugs to improve health outcomes.

Consensus of Spanish Society of Hospital Pharmacy on optimal medication therapy management of atopic dermatitis

AIM

This study's aims are: 1) To use the Delphi method to determine the level of consensus among hospital pharmacists (HPs) as regards the factors involved in the current approach to patients with atopic dermatitis (AD); 2) To identify potential areas for improvement in hospital pharmacy in terms of dealing with patients with severe AD; and 3) To contribute to adequate pharmaceutical care for patients with AD by drawing up recommendations.

METHODS

A two-round Delphi survey with participation from HPs from all over Spain. Three theme-based blocks were set out: 1) AD; 2) Management of patients with severe AD in the Hospital Pharmacy setting; and 3) Unmet needs (pathology, patient, treatment and management).

RESULTS

The 42 HPs participating reached a consensus in recognising the impact of severe AD on the patients suffering from it, the need to encourage adherence and the recommendations to use scales that take into account the patient's quality of life and indicators of the patient's experience. It has also been demonstrated that it is worthwhile evaluating the results in real clinical practice in consensus with other specialists from the multidisciplinary team. Finally, it is advisable to use drugs that have demonstrated long-term effectiveness and safety for patients with severe AD, given the disease's chronic nature.

CONCLUSIONS

This Delphi consensus highlights the impact of severe AD on patients, the importance of a multidisciplinary and holistic approach, in which HP play a major role. It also highlights the importance of increased access to new drugs to improve health outcomes.

National Saudi Consensus Statement on the Management of Atopic Dermatitis (2021)

Atopic dermatitis (AD) is a chronic inflammatory skin disease with an increasing prevalence regionally and globally. It is characterized by intense itching and recurrent eczematous lesions. With the increase in the availability of treatment options for healthcare practitioner and patients, new challenges arise for treatment selection and approach. The current consensus statement has been developed to provide up-to-date evidence and evidence-based recommendations to guide dermatologists and healthcare professionals managing patients with AD in Saudi Arabia. By an initiative from the Ministry of Health (MOH), a multidisciplinary work group of 11 experts was convened to review and discuss aspects of AD management. Four consensus meetings were held on January 14, February 4, February 25, and March 18 of 2021. All consensus content was voted on by the work group, including diagnostic criteria, AD severity assessment, comorbidities, and therapeutic options for AD. Special consideration for the pediatric population, as well as women during pregnancy and lactation, was also discussed. The present consensus document will be updated as needed to incorporate new data or therapeutic agents.

Treatment Guidelines for Atopic Dermatitis Since the Approval of Dupilumab: A Systematic Review and Quality Appraisal Using AGREE-II

Introduction

Since its approval for adults with moderate-to-severe atopic dermatitis (AD) in 2017, dupilumab has been incorporated into clinical practice guidelines (CPGs). However, recommendations differ internationally, and the quality assessment of their development is unclear.

Objective

We aimed to systematically review and appraise the quality of CPGs for adult AD reported since 2017 and map the recommendations for dupilumab initiation relative to conventional systemic therapy (CST).

Materials and Methods

A literature search was conducted in June 2020 in MEDLINE, EMBASE, SCOPUS, and CINAHL. Twelve CPGs were retrieved. Methodological quality was assessed using the validated Appraisal of Guidelines for Research & Evaluation II tool (AGREE-II). Recommendations were extracted and compared.

Results

AGREE-II median scores per domain of the CPGs were (%, r = range): scope/purpose, 78% (50-96); stakeholder involvement, 54% (28-85); rigor of development, 39% (21-63); clarity of presentation, 85% (69-100); applicability, 27% (6-51); and editorial independence, 76% (42-100). Neither met the threshold of 70% quality criteria for rigor of development nor the applicability domains. Three CPGs met the criteria for recommendation without modification. CPGs' approach to dupilumab initiation was as follows: second line, preferred over CST and nbUVB (n = 1/12 CPG); second line, equivalent to CST or nbUVB (n = 3/12 CPGs); third line, after nbUVB or CST (n = 5/12 CPGs); and fourth line after nbUVB and CST (n = 2/12). No consensus was reached for n = 1/12 CPG.

Conclusion and Relevance

Dupilumab is now incorporated into CPGs for adult AD. These CPGs exhibited good quality in scope/purpose, clarity, and editorial independence domains. However, none met AGREE-II criteria for methodological rigor/applicability. Gaps were found in mechanisms for updates, facilitators/barriers, resource implications, and stakeholder involvement. Only n = 3/12 CPGs met quality criteria for recommendation without modifications. Of these, two favored a conservative sequential approach for the initiation of dupilumab relative to CST, while one did not reach consensus. Our findings highlight divergent recommendations AD treatment, underlining a need to incorporate quality criteria into future guideline development.

Global Guidelines in Dermatology Mapping Project (GUIDEMAP) - a systematic review of atopic dermatitis clinical practice guidelines: are they clear, unbiased, trustworthy and evidence based (CUTE)?

BACKGROUND

Clinical practice guidelines (CPGs) are essential in delivering optimum health care, such as for atopic dermatitis (AD), a highly prevalent skin disease. Although many CPGs are available for AD, their quality has not been critically appraised.

OBJECTIVE

To identify CPGs on AD worldwide and assess with validated instruments if those CPGs are clear, unbiased, trustworthy and evidence based (CUTE).

METHODS

We searched MEDLINE, Embase, PubMed, Web of Science, Cochrane Library, Emcare, Epistemonikos, PsycINFO and Academic Search Premier for CPGs on AD published between 1 April 2016 and 1 April 2021. Additionally we hand searched prespecified guideline resources. Screening, data extraction and quality assessment of eligible guidelines were independently carried out by two authors. Instruments used for quality assessment were the Appraisal of Guidelines for Research and Evaluation (AGREE) II Reporting Checklist, the U.S. Institute of Medicine's (IOM) criteria of trustworthiness and Lenzer's Red Flags.

RESULTS

Forty CPGs were included, mostly from countries with a high socio-demographic index. The reported quality varied enormously. Three CPGs scored 'Excellent' on all AGREEII-domains: Columbia, the Netherlands and United Kingdom (UK; antimicrobials). Three CPGs scored 'Poor' on all domains: Poland (phototherapy), Romania and Serbia. We found no association between AGREEII-scores and a country's gross domestic product. One CPG fully met all nine IOM criteria (Malaysia) and two fully met eight (European dupilumab and UK antimicrobials). Three CPGs had no red flags: Malaysia, South Korea and UK antimicrobials. 'Applicability' and 'Rigour of development' were the lowest scoring AGREEII domains; 'Lack of external review', 'Updating procedures' and 'Rating strength of recommendations' met the least IOM criteria; and most red flags were for 'Limited or no involvement of methodological expertise' and 'No external review'. Management of conflict of interests (COI) appeared challenging. When constructs of the instruments overlapped, they showed high concordance, strengthening our conclusions.

CONCLUSIONS

Overall, many CPGs are not clear, unbiased, trustworthy or evidence based (CUTE) enough and lack applicability. Therefore improvement is warranted, for which using the AGREEII instrument is recommended. Some improvements can be easily accomplished through robust reporting. Others, such as transparency, applicability, evidence foundation and managing COI, might require more effort.

Melatonin and sleep disorders in patients with severe atopic dermatitis

Introduction

Many atopic dermatitis (AD) patients suffer from insomnia. Out of numerous factors associated with sleep disorders, melatonin seems to play a significant role.

Aim

To assess the relation between melatonin concentration and sleep disorders in adult patients with severe and very severe AD.

Material and methods

The study included 36 adult patients with severe and very severe AD and 20 healthy Caucasian volunteers. The severity of skin lesions was assessed by the EASI scale. Skin itch was evaluated by a visual-analogue scale (VAS), and sleep disorders were assessed by the Polish version of the Athens Insomnia Scale (AIS). Serum melatonin concentration of patients and controls was determined by ELISA.

Results

Melatonin concentration in patients with very severe AD was significantly (p < 0.001) lower than in patients with severe AD, however, melatonin concentration in the group of AD patients did not differ significantly (p = 0.33) from that observed in the control group. There was a significant negative correlation between the concentration of melatonin in the study group and the severity of itching (R = -0.54, p < 0.001). The intensity of sleep disorders was significantly higher (p < 0.001) in patients with a very severe form of AD compared to patients with severe AD. Moreover, there was a significant negative correlation between melatonin concentration and sleep disorders (R = -0.67, p < 0.001).

Conclusions

Our results clearly showed that sleep disturbances are more expressed in very severe AD patients compared to subjects suffering from severe disease. We also suggest that melatonin serum concentration could play a role in the pathogenesis of sleep disturbances in AD patients.

Dermatitis in community pharmacies: a survey on italian pharmacists’ management and implications on corticophobia

Community pharmacists represent an important resource for the promotion of a safer and more effective self-management of common skin diseases, as well as the provision of educational support on therapies prescribed by clinicians, ultimately improving patients’ adherence. In this study, a semi-structured survey was administered to 154 Italian community pharmacists, in order to acquire information on their counseling activity on dermatological disorders. Collected data provide an overview on the frequency and methodology of counseling offered in Italian community pharmacies, identifying knowledge gaps and misbeliefs. In particular, an overall negative opinion on topical corticosteroid therapy emerged among pharmacists, unveiling a phenomenon previously described as corticophobia. Starting from this observation, we discuss the risks for patients’ adherence, associated with corticophobia among pharmacists. Lastly, we briefly report on the main tools desired by pharmacists to improve their education on dermatology, envisioning their implementation with the aim of a more effective counseling.

Unmet needs in atopic dermatitis management: an expert consensus

INTRODUCTION

Atopic dermatitis (AD) has substantial negative impact on patients' quality of life. Although considerable advances have been made in understanding the pathogenesis and its treatment, there is still limited transfer of this knowledge into daily management. Aiming to identify unmet needs in clinical management of patients with AD, we used a Delphi consensus process.

METHODS

A set of statements regarding diagnosis, management, prognosis, and treatment was identified by five experts (Steering Committee). Then, the Steering Committee and a second group of four clinicians were involved in a Delphi process. Lastly, agreement was assessed in a larger panel of Italian clinicians.

RESULTS

Overall, 37 clinicians participated to the process. 17 statements reached strong agreement and 2 reached weak agreement.

CONCLUSIONS

In general, the statements reflected the need for accurate and effective diagnostic criteria to support clinical experience, especially in the atypical forms of AD. Moreover, prognostic criteria are needed to predict the duration of adult-onset AD. The identification of biomarkers was considered to be useful for clinical management of AD at all stages of disease. Lastly, greater emphasis should be placed on patient education and development of effective tools that can aid informing patients about their disease and its treatment.

Prevalence, incidence and management of atopic dermatitis in Australian general practice using routinely collected data from MedicineInsight

Background/Objectives

The 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.

Methods

This 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.

Results

The 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%).

Conclusions

Our 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.

Pruritus Characteristics in Severe Atopic Dermatitis in Adult Patients

Atopic dermatitis (AD) is classified as a most common inflammatory skin disease. The condition is characterized by recurrent eczematous lesions and intense pruritus or itch, a hallmark of AD. The aim of this study was to identify the provoking factors of itch in severe AD adult patients. There were 34 adult patients suffering from AD of the median age of 40 years enrolled into the study and a control group that consisted of 20 healthy subjects. The severity of AD was assessed with the SCORing Atopic Dermatitis (SCORAD) index, pruritus intensity was assessed on a visual analog scale (VAS), and itch aggravating factors were assessed with a questionnaire. Specific IgE (sIgE) antibodies and interleukin IL-33 were measured in venous blood. We found that all the patients with severe AD had intensive itch (VAS: 9-10 points) during the whole day and 30 (88.2%) patients had it during nighttime. The most significant factors aggravating itch were the following: dry skin (27 patients; 79.4%), exposure to dust mite (22 patients; 64.7%,), and emotional distress (17 patients; 50%). Moreover, there was a positive correlation between the intensity of itch and the level of sIgE antibodies to dust mite (p < 0.001). The content of IL-33 was significantly higher in AD patients with severe skin lesions. This exploratory study shows that skin dryness, dust exposure, and distress play an essential role in the exacerbation of AD in the adult population.