Atopic dermatitis shows significant cutaneous comorbidity: results from large‐scale investigations in the working population

Recent insights into comorbidities in atopic dermatitis

INTRODUCTION

The relationship between atopic dermatitis and atopic diseases such as food allergies, asthma, and allergic rhinitis in terms of co-occurrence, underlying mechanisms, and therapy is well documented. There is increasing evidence that atopic dermatitis is associated with non-atopic comorbidities such as cardiac, autoimmune, and neuropsychological comorbidities, as well as cutaneous and extracutaneous infections, establishing atopic dermatitis as a systemic disease.

AREAS COVERED

The authors reviewed evidence on atopic and non-atopic comorbidities of atopic dermatitis. A literature search was conducted in PubMed for peer-reviewed articles published until October 2022.

EXPERT OPINION

Atopic and non-atopic diseases coexist with atopic dermatitis more often than would be expected by chance. The effect of biologics and small molecules on atopic and non-atopic comorbidities may contribute to a better understanding of the relationship between atopic dermatitis and its comorbidities. Their relationship needs to be explored further to dismantle the underlying mechanism and move toward an atopic dermatitis endotype-based therapeutic approach.

Dupilumab Treatment of Atopic Dermatitis in Routine Clinical Care: Baseline Characteristics of Patients in the PROLEAD Prospective, Observational Study

Introduction

Dupilumab is the first biologic licensed to treat patients with moderate-to-severe atopic dermatitis (AD) who require systemic therapy. PROLEAD was designed to document the real-world effectiveness and safety of dupilumab in patients with moderate-to-severe AD. The present study aims to describe the baseline characteristics of patients treated with dupilumab in Germany.

Methods

PROLEAD is a national, multicentre, prospective, non-interventional study, with a 2-year observation period. Adults with moderate-to-severe AD treated with dupilumab were included. Baseline characteristics, physician assessments, and patient-reported outcomes (PROs) were collected.

Results

The study involved 126 sites throughout Germany. Of 839 patients assessed for eligibility, 828 were included, with baseline data available for 817 patients. Mean (standard deviation, SD) age of patients was 43.4 (15.8) years, with 396 (48.5%) patients being female. Overall, 66.6% of patients received their first diagnosis of AD during childhood. In total, 423 (51.8%) patients had co-existing atopic and type 2 inflammatory diseases, including allergic conjunctivitis (36.8%) and bronchial asthma (22.5%). Overall, 61.4% of patients had received systemic therapy, most commonly oral corticosteroids (49.9%). Approximately half of patients (51.3%) had received UV/phototherapy prior to baseline. Treatment with moderate-potent (Class 2) or potent (Class 3) topical corticosteroids was the most common concomitant treatment at baseline. However, 50.4% of patients had not received concomitant AD treatment with dupilumab at baseline. The most reported reason for initiating dupilumab was “Topical therapy alone was not sufficient” (95.1%). Mean (SD) physician assessments: EASI: 22.9 (14.5); SCORAD: 63.3 (16.2); IGA: 3.3 (0.7). Mean (SD) PROs: DLQI: 13.9 (7.1); peak pruritus NRS: 7.4 (2.3).

Conclusions

Patients with moderate-to-severe AD present a long medical history, impaired quality of life, and high prevalence of co-existing type 2 inflammatory diseases. Dupilumab was used as a first-line systemic treatment in 38.6% of patients.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13555-022-00791-1.

Unveiling the true costs and societal impacts of moderate-to-severe atopic dermatitis in Europe

Atopic dermatitis (AD) is a chronic, auto-immune condition that imposes a high burden on individuals, society, and the healthcare system. Approximately 4.4% of adults and up to 18.6% of children/adolescents have AD in Europe, with 20% of all cases accounting for moderate-to-severe forms. This form of the condition in adults results in annual societal costs across Europe of an estimated €30 billion; €15.2 billion related to missed workdays or reduced work productivity, €10.1 billion related to direct medical costs and €4.7 billion related to personal expenditure of patients/families. AD can also substantially impact physical, emotional, and social quality-of-life. Several studies have shown the debilitating itch-scratch cycle is the main cause of the multifaceted burden, as it causes substantial sleep deprivation and stigmatisation due to the physical appearance of the skin, and confidence issues. These factors lead to psychosocial issues and can cumulate over time and prohibit patients reaching their 'full life potential'. Despite this, many patients with the condition are undertreated, resulting in uncontrolled symptoms and a further strain placed on patients, society, and the economy. The authors of this White Paper comprise the European Atopic Dermatitis Working Group, which is a network of international specialists with expertise in dermatology and healthcare policy decisions. Their programme of action is focused on harnessing their expertise to build consensus, advance research, share knowledge, and ultimately seek to improve AD care outcomes through achieving long-term symptom control. This White Paper presents a systematic evaluation of the overall financial and humanistic burden of moderate-to-severe AD and the current challenges that exist with AD care. It introduces recommendations for how, collaboratively, key stakeholders and policy makers can support improvements in AD management to achieve better disease control, thus reducing the costs and associated burden placed on individuals, society, and the economy.

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.

Epidemiology of skin diseases in Germany: systematic review of the current state of research - part 2: non-infectious skin diseases

The aim of this work was to systematically collect all previously published population-based epidemiological data on skin diseases in Germany. The present part 2 of the publication series deals with non-infectious skin diseases. The results on cutaneous tumor diseases (part 1) and infectious skin diseases (part 3) form the other parts of this publication series. A systematic literature search was performed using PubMed/MEDLINE for the period of the last 15 years. With the aim of including all dermatologic diseases, a diagnostic list was developed based on the ICD-11 catalogue. This list included 1,347 skin diseases and formed the basis for the search. The literature search yielded 4,650 hits, of which 72 were included in the synthesis. Among them were 37 publications on non-infectious skin diseases. Among these, psoriasis and atopic eczema were the most common. The highest lifetime prevalence was found for acne. This work is the first systematic literature review that aimed to report all available epidemiological data on skin diseases in Germany. It was found that representative data on many non-infectious diseases are not yet available. Among the included studies, there was a high heterogeneity regarding the methodology. Nevertheless, the utility of these epidemiological data is wide-ranging and can serve as a reference of various epidemiological questions.

[Regional variations in healthcare for patients with psoriasis and atopic dermatitis in Germany]

BACKGROUND

Psoriasis (Pso) and atopic dermatitis (AD) are chronic skin diseases that result in significant physical and psychological impairment, financial burden, and loss of quality of life. According to previous data, there are regional differences in healthcare.

OBJECTIVES

The aim was to analyse the epidemiology as well as the treatment of insured people with Pso and AD in Germany in a regional comparison.

METHODS

Data of the insurance company Techniker Krankenkasse for the year 2019 regarding treatment prevalences as well as drug prescriptions on the regional level for all physicians were examined.

RESULTS

In 2019 the overall prevalence of Pso was 2.5% (about 2 million insured people in Germany) and AD was 4.2% (about 3.6 million insured people). In Pso, new guideline-compliant drugs were frequently utilised, yet systemic glucocorticosteroids (GCS) were still disproportionally prescribed. Regionally, there were pronounced disparities with higher prescription rates of the new drugs in the north and east. Insured people with AD most frequently received topical GCS (approx. 88%), of which most were class III (66%), and significantly less frequently calcineurin inhibitors (< 10%), which also conform to guidelines. Systemically, GCS were by far most commonly used (about 25% of all insured people with drug prescriptions). Dupilumab, the only long-term drug approved in 2019, was very rarely prescribed, accounting for less than 1%. Again, large regional differences similar to Pso were found.

CONCLUSION

Pso and AD show relevant disparities and gaps in drug care in the regional comparison despite uniform national guidelines and patient needs. The barriers to appropriate modern pharmaceuticals need to be clarified and mitigated.

[Quality of care for patients with atopic dermatitis in Germany-no improvements in indicators after ten years]

Hintergrund

Mit AtopicHealth1 wurde 2010 die erste nationale Versorgungsstudie zur AD durchgeführt. Damals zeigte etwa ein Drittel der Patienten, die sich in einer Behandlung bei Dermatologen befanden, starke Einschränkungen der Lebensqualität, was auf eine unzureichende Versorgungsqualität hindeutete. Ziel der vorliegenden Studie war die Charakterisierung der aktuellen Versorgung von Patienten mit Neurodermitis in dermatologischer Behandlung im Schweregradvergleich sowie im Vergleich zu 2010 und zu Psoriasis.

Methode

Die deutschlandweite multizentrische Querschnittstudie „AtopicHealth2“ erfasste klinische Daten, Lebensqualität (DLQI), Therapien, präventives Verhalten und patientendefinierten Behandlungsnutzen (PBI). Patienten mit einer Indikation für Systemtherapie wurden für Subgruppenanalysen als mittelschwer bis schwer, die anderen als leicht betroffen angesehen.

Ergebnisse

Zwischen 2017 und 2019 wurden 1291 Patienten durch 111 Zentren eingeschlossen, mittleres Alter 41 Jahre, 56,5 % weiblich. Im Vergleich zu 2010 fanden sich keine Verbesserungen hinsichtlich Lebensqualität (jeweils DLQI 8,5), Schweregrad (SCORAD 45,4 vs. 42,3 in 2010) und Therapienutzen (PBI 2,2 vs. 2,4 in 2010). Mittelschwer bis schwer betroffene Patienten zeigten häufiger Lebensqualitätseinbuße (45,4 % vs. 23,6 %) und seltener relevante Therapienutzen (PBI < 1: 21,3 % vs. 13,2 %) als leichter betroffene. Verglichen mit Psoriasis offenbarten die Patienten mit Neurodermitis höhere Lebensqualitätseinschränkungen (DLQI 8,5 vs. 6,1) und einen geringeren Behandlungsnutzen (PBI 2,2 vs. 2,8).

Diskussion

Im Vergleich zu 2010 zeigt sich keine verbesserte Versorgungsqualität von Neurodermitis in Deutschland. Im Vergleich zur Psoriasis weisen Patienten mit Neurodermitis höhere Belastungen und geringere therapeutische Nutzen auf, was den Bedarf an therapeutischen Innovationen unterstreicht.

Prevalence and Medications of Atopic Dermatitis in Germany: Claims Data Analysis

Background

Information on the prevalence of atopic dermatitis (AD) varies greatly, and so far, only a few studies describe the healthcare of patients with AD in Germany.

Objective

The aim of the study is to describe the prevalence and medications of people with AD in Germany.

Methods

Health insurance data for the year 2019 were examined. Prevalence rates, the severity of disease, comorbidities and pharmaceutical supply were analyzed. Insured persons with AD were identified with at least one outpatient or inpatient International Classification Code of Diseases (L20).

Results

In 2019, 4.21% [95% CI 4.21−4.22%] of insured persons had AD (3.6 million). Women were affected slightly more frequently than men (4.74% [95% CI 4.73−4.74%] and 3.64% [95% CI 3.64−3.65%]). Adolescents and children under the age of 15 had the highest prevalence of AD compared to other age groups (9.44% [95% CI 9.42−9.46%]). Majority of the insured persons with AD were affected by a mild to moderate form of the disease. The most common co-morbidity was infections of the skin (RR 5.00 [95% CI 4.97−5.02%]). Some patients were treated by a dermatologist, while others by a general practitioner, 39.10% and 36.74%, respectively. Of the anti-inflammatory drugs, systemic glucocorticosteroids preparations were used most frequently and were most frequently prescribed by the general practitioner. With a total of 42,841 prescriptions (1.53%), methotrexate (third-line treatment option) was prescribed more frequently than ciclosporin with 19,628 prescriptions (0.70%) or azathioprine with 25,696 prescriptions (0.92%). Ciclosporin (first-line treatment option) was prescribed much more frequently by a dermatologist (44.00% versus 14.32% by general practitioner). The biological dupilumab was prescribed 30,801 times (1,10%) and was also primarily prescribed by a dermatologist (66.67%).

Conclusion

The present results reveal that a specialist treats approximately one-third of the patients with AD and that there is still a drug undersupply in some cases, especially concerning innovative drugs.

Adherence to Guideline-Oriented Preventive Measures in Patients with Atopic Dermatitis in Germany

BACKGROUND

Atopic dermatitis (AD) is a chronic inflammatory skin disease that is often associated with comorbidities and quality of life losses. The implementation of evidence-based preventive measures strengthens patient participation and offers the potential to improve quality of care for AD.

OBJECTIVES

To assess adherence to guideline-oriented preventive measures in adult patients with AD in dermatological routine care in Germany.

METHODS

The self-responsible application of preventive measures, clinical features, pruritus, disease severity, and duration of disease as well as skin disease-related quality of life were assessed in two independent cross-sectional studies in 2010 and 2017-2019.

RESULTS

Between 2017 and 2019, 706 patients (55.8% female, mean age 41 years) were recruited in a comparable way to the survey in 2010 with 1,678 patients (60.5% female, mean age 38 years). Regular skin care was applied by 99.5% (2010: 94.9%), 90.9% avoided skin irritants (2010: 84.6%), and 80.2% (2010: 61.6%) did not smoke at home. Relaxation techniques were applied by 44.4% (2010: 29.9%). Advice on self-help measures was taken by 36.4% (2010: 27.1%) and 29.2% (2010: 15.4%) attended AD patient education courses. All six preventive measures categorized as obligatory were performed by 13.9% of the patients (2010: 6.7%). Predictors for the number of obligatory preventive measures applied were a high level of education, a longer disease duration, and a lower quality of life.

CONCLUSIONS

Although the self-reported use of evidence-based preventive measures in the 2017-2019 study appears to be more frequent than in 2010, important measures are still insufficiently established. Hence, more implementation, including education, is needed to increase the use of guideline-oriented preventive measures.

Can atopic eczema and psoriasis coexist? A systematic review and meta-analysis

Importance

Previous studies report both coexistence and mutual exclusivity of atopic eczema (AE) and psoriasis, but these have not been appraised systematically. Knowledge of such disease association throws light on disease mechanisms and may influence therapeutic choices.

Objective

To summarise evidence for AE and psoriasis occurring in the same person at the same point in time. Planned primary outcome was the incidence, prevalence or risk of psoriasis or eczema.

Methods

Ovid MEDLINE and Ovid Embase were searched from inception to 1st February 2020. The search strategy was built around the key terms ‘atopic eczema’, ‘psoriasis’ and ‘co‐existence’. Observational studies (cohort, case‐control, cross‐sectional and case‐series) with a minimum of 10 consecutive patients were included. There were no restrictions on participants, geography or language. Studies were selected, data extracted and critically appraised by two independent reviewers. Data were extracted on the method of diagnosis: health professional (dermatologist, criteria, other), self‐reported, not specified. Study quality was assessed using validated Joanna Brigg's Institute critical appraisal tools. A random‐effects model was used to combine studies. The effect of study quality on the pooled estimate was investigated using stratification. Heterogeneity was explored by subgroup analysis.

Results

This review included 31 studies and 20 523 individuals with psoriasis and 1 405 911 with AE. Eight studies reported the prevalence of AE in those with psoriasis and values ranged from 0.17% to 20%: the pooled prevalence was 2% (95% confidence interval [CI]: 1, 3). Seven studies reported the prevalence of psoriasis in those with AE and values ranged from 0.3% to 12.6%; the pooled prevalence was 2% (95% CI: 1, 3). Ten studies were assessed as low risk of bias. Geographical area, method of diagnosis, setting and whether the assessment of diagnosis was blinded, partly contributed to the heterogeneity.

Conclusions

This review provides some evidence for the coexistence of AE and psoriasis. Clinicians should be aware of coexistence at diagnosis, when selecting therapies and when reviewing poor response to treatment.

Comorbidités de la dermatite atopique

Atopic dermatitis is associated with an increased risk of asthma (10 to 30% according to age), allergic rhinitis and conjunctivitis and food allergy. Other comorbidiies are globally lest frequent than in psoriasis. There is no increased risk of solid cancer. Smoking is a major confounding factor that has to be taken into account. Obesity and metabolic syndrome are more frequent and there is a moderately increased cardiovascular risk in severe forms of atopic dermatitis. There is a clear-cut increased risk of vitiligo and alopecia areata and a lower risk of other auto-immune diseases, including type I diabetes in children. There is a higher risk of cutaneous but not extra-cutaneous bacterial and viral infections, and increased frequency of contact dermatitis and urticaria. Severe atopic dermatitis is associated with psychiatric comorbidities, like attention disorders/hyperactivity, depression and suicidal ideas. © 2019 Elsevier Masson SAS. All rights reserved.

Management of Moderate-to-Severe Atopic Dermatitis in the Era of Targeted Treatments

Prof Augustin opened the symposium by underlining how the management of patients with moderate-to-severe atopic dermatitis (AD) has become more dynamic over the past 2 years following the approval of the first biologic agent, dupilumab, in 2017. Prof Augustin explained that moderate-to-severe AD is a chronic Type II inflammatory disease that has significant effects on patients’ and caregivers’ lives. The multidimensional disease burden of AD, which includes signs and symptoms that impact physical, mental, social wellbeing, and quality of life (QoL), is proportional to disease severity and lack of disease control. Sustained control of moderate-to-severe AD is essential to limit the burden caused by the disease. In the second presentation, Dr Simpson emphasised the importance of pointing out to each patient that AD is a chronic disease that requires long-term management. When discussing goals and treatment options with each patient, the importance of sustainable disease management should be emphasised. He presented outcomes from recent clinical trials investigating the long-term efficacy and safety of targeted agents in patients with AD. In the final presentation, Dr de Bruin-Weller discussed the importance of real-world evidence when considering treatment options for patients with AD. Real-world evidence for the effectiveness and tolerability of treatments can be gleaned from a number of sources, including registry-based clinical experience, survey data, centre-based clinical experience, and case studies. Consideration of real-world evidence, alongside outcomes from randomised controlled trials, enables selection of the most appropriate treatment option for each patient.