Awareness of and phobias about topical corticosteroids in parents of infants with eczema in Hangzhou, China

Experts' Consensus on the Use of Pimecrolimus in Atopic Dermatitis in China: A TCS-Sparing Practical Approach

Introduction

Atopic dermatitis (AD) is a chronic, pruritic, inflammatory skin disease with rising prevalence. Topical corticosteroids (TCS) are recommended as first-line therapy for patients with AD in China; however, corticophobia is a widespread concern, which can manifest as noncompliance: in a previous Chinese study, almost all parents whose children had AD were very concerned about the side effects of TCS and, as a result, nearly half did not use it in the event of recurrence. We propose a TCS-sparing treatment algorithm for the management of infants, children, adolescents, and adults with mild-to-moderate AD, to guide clinical practice in China.

Methods

A panel of eight experts in AD from China and one expert from Germany formed to develop a practical algorithm for the management of mild-to-moderate AD, focusing on pimecrolimus.

Results

Irrespective of body location, all patients with mild AD (including acute flares) and infants with moderate AD should apply the topical calcineurin inhibitor (TCI) pimecrolimus twice daily to the affected area until symptoms disappear. For children, adolescents, and adults with moderate AD, pimecrolimus should be applied twice daily to sensitive skin areas, and a TCI (either pimecrolimus or tacrolimus) should be applied twice daily to other body locations. Short-term administration of TCS, followed by TCI twice daily, is recommended for most patients with moderate AD experiencing acute flares, regardless of lesion site. Emollients should be used regularly.

Conclusions

The algorithm presented intends to simplify treatment of AD in China and guide clinical decision-making.

Steroid Phobia: A Review of Prevalence, Risk Factors, and Interventions

Topical corticosteroid phobia may lead to poor adherence, resulting in persistent disease and escalation to systemic agents. The aim of this paper was to review current literature to assess topical steroid phobia prevalence, populations most at risk, reasons behind steroid phobia, and interventions to reduce it. A systematic search of PubMed, Ovid (Journals@Ovid, MEDLINE), ScienceDirect, and Web of Science was performed. Studies ranged from May 2000 to February 2021. In total, 37 articles met the inclusion criteria. There was inter-study variation in the way steroid phobia is defined, from concern to irrational fear. The worldwide prevalence of topical steroid phobia ranges from 31 to 95.7% and does not differ with patient race/ethnicity or dermatological condition. Female patients and caregivers, and those who have experienced side effects of topical corticosteroids are most likely to express steroid phobia. Reasons for steroid phobia include lack of education, fear of side effects, polypharmacy, misinformation, negative experience with topical steroids, and frequently changing of clinics. Successful interventions to address steroid phobia include patient education in the form of educational videos followed by individualized oral education based on concerns, and demonstrations of application of topical steroids. Multiple interventions address topical corticosteroid phobia and improve adherence of topical corticosteroids in the management of dermatological conditions. Providers should screen patients for steroid phobia, especially in populations particularly at risk. Interventions using patient education should be individualized based on concerns expressed during screening. Further research should investigate if reducing steroid phobia can in fact improve long-term adherence.

Practical algorithm to inform clinical decision-making in the topical treatment of atopic dermatitis

Atopic dermatitis is a chronic relapsing, inflammatory skin disorder associated with skin barrier dysfunction, the prevalence of which has increased dramatically in developing countries. In this article, we propose a treatment algorithm for patients with mild-to-moderate and severe atopic dermatitis flares in daily clinical practice. An international panel of 15 dermatology and allergy experts from eight countries was formed to develop a practical algorithm for the treatment of patients with atopic dermatitis, with a particular focus on topical therapies. In cases of mild-to-moderate atopic dermatitis involving sensitive skin areas, the topical calcineurin inhibitor pimecrolimus should be applied twice daily at the first signs of atopic dermatitis. For other body locations, patients should apply a topical calcineurin inhibitor, either pimecrolimus or tacrolimus, twice daily at the first signs of atopic dermatitis, such as pruritus, or twice weekly in previously affected skin areas. Emollients should be used regularly. Patients experiencing acute atopic dermatitis flares in sensitive skin areas should apply a topical corticosteroid twice daily or alternate once-daily topical corticosteroid/topical calcineurin inhibitor until symptoms improve. Following improvement, topical corticosteroid therapy should be discontinued and patients switched to a topical calcineurin inhibitor. Maintenance therapy should include the use of pimecrolimus once daily for sensitive areas and tacrolimus for other body locations. This treatment algorithm can help guide clinical decision-making in the treatment of atopic dermatitis.

Epidemiology, Diagnosis, and Treatment of Atopic Dermatitis in the Developing Countries of Asia, Africa, Latin America, and the Middle East: A Review

Atopic dermatitis (AD), the leading cause of skin-related burden of disease worldwide, is increasing in prevalence in developing countries of Asia, Africa, Latin America, and the Middle East. Although AD presents similarly across racial and ethnic groups as chronic and relapsing pruritic eczematous lesions, some features of the disease may be more or less prominent in patients with darker skin. Despite a similar presentation, consistent diagnostic criteria and consistent treatment guidelines are lacking. Because of these and other challenges, adherence to treatment guidelines is difficult or impossible. Previous studies have stated that many patients with AD receive ineffective or inappropriate care, such as oral antihistamines, oral corticosteroids, or traditional medicines, if they are treated at all; one study showed that approximately one-third of patients received medical care for their dermatologic condition; of those, almost three-quarters received inappropriate or ineffective treatment. In addition, other challenges endemic to developing countries include cost, access to care, and lack of specialists in AD. Furthermore, most of the available diagnostic criteria and treatment guidelines are based on European and North American populations and few clinical trials report the racial or ethnic makeup of the study population. Drug pharmacokinetics in varying ethnicities and adverse effects in different skin physiologies are areas yet to be explored. The objective of this review is to describe the diagnosis, treatment, and management of AD in developing countries in Asia, Africa, Latin America, and the Middle East; to discuss the differences among the countries; and to establish the unmet needs of patients with AD in them. The unmet medical need for treatment of AD in developing countries can be addressed by continuing to train medical specialists, improve access to and affordability of care, and develop new and effective treatments.Funding Pfizer Inc.

Eczema apps conformance with clinical guidelines: a systematic assessment of functions, tools and content

BACKGROUND

Eczema is a prevalent complex skin condition requiring active disease monitoring and personalized education. No studies have assessed the quality of apps that aim to support eczema self-management.

OBJECTIVES

To evaluate the quality and comprehensiveness of English, Chinese and Spanish self-management eczema smartphone apps for patients and/or their caregivers.

METHODS

A systematic assessment of eczema apps from July 2018 to November 2018. The assessment criteria were based on conformance with international eczema guidelines. The following domains were assessed: consistency and comprehensiveness of eczema-specific educational information; quality and comprehensiveness of eczema-specific tracking functions; compliance with health information best practice principles.

RESULTS

In total, 98 apps were assessed: 82 (84%) provided educational information; 38 (39%) tracking functions; and 13 (13%) both. We found that 34% (28/82) of apps provided misleading information, particularly regarding aspects of treatment and disease progression of eczema. Only 15% (12/82) provided international guideline supported information on pharmacological therapies and 16% (13/82) on nonpharmacological therapies. Among 38 apps with a tracking function, 82% (31/38) measured specific symptoms, disease severity or current skin condition and 89% (34/38) helped users to record medication usage including application of topicals. Environmental or dietary allergens were recorded by 34% (13/38). None of the included apps complied with all criteria for educational information, tracking functions or health information principles.

CONCLUSIONS

Eczema apps have not yet reached their potential. The large variance in quality of eczema apps highlights the need for quality assurance mechanisms for health apps and guidance for clinicians that would enable them to make personalized recommendations for patients and caregivers. What's already known about this topic? There is limited information about the quality of eczema self-management smartphone apps on the global market. What does this study add? This systematic assessment evaluated all English, Chinese and Spanish language apps that support eczema self-management. The majority did not conform with information in guidelines and insufficiently support evidence-based self-management. The large variance in the quality of eczema apps highlights the need for mechanisms to ensure app quality and to guide personalized app selection for patients, caregivers and doctors.