Updates on the Treatment of Atopic Dermatitis

Atopic dermatitis, also known as eczema, is a common inflammatory skin condition that is characterized by dry, pruritic skin with a chronic relapsing course. Patients with atopic dermatitis may have to endure the social stigma of having a visible skin condition as well as intense itching that can lead to skin trauma and significant sleep disturbances, thereby adversely affecting quality of life (QOL). Researchers continue to study the safety and efficacy of novel agents for the treatment of atopic dermatitis, as well as patient- and disease-related factors that can affect patient outcomes.

This article provides an overview of results from key studies on atopic dermatitis that were scheduled to be presented at the American Academy of Allergy, Asthma, and Immunology’s annual meeting, which was canceled because of the COVID-19 crisis.

Real-World Practices and Perceptions Regarding SDM and QoL

Uncontrolled moderate-to-severe atopic dermatitis can significantly affect patients’ health, QOL, and productivity. Engaging in shared decision-making (SDM) and accounting for patient-reported outcomes in treatment decisions can improve the assessment and treatment of the atopic dermatitis, resulting in improved patient-centered care. In the context of a quality improvement study, Christopher Codispoti, MD, PhD, Allergist and Immunologist, Rush University Medical Center, Chicago, IL, and colleagues evaluated real-world patient-centered atopic dermatitis care practices and perceptions among healthcare professionals in 2 large US healthcare systems.1

Physicians, physician assistants, and nurse practitioners from 23 allergy/immunology clinics and 28 dermatology clinics across 2 health systems reported that they most of the time or always assess the impact of atopic dermatitis on patient-reported measures, including daily activities (allergy/immunology specialists, 39%; dermatologists, 43%), sleep quality (allergy/immunology specialists, 35%; dermatologists, 39%), and mental health (allergy/immunology specialists, 17%; dermatologists, 46%). Based on the chart review, low proportions documented that patients were queried regarding daily activities (19%), sleep quality (10%), or depression (5%).

For some SDM practices, chart-documented performance was high, including assessing adherence (92%) and providing opportunities to review decisions (78%). However, performance was low in terms of providing opportunities for patients to ask questions (39%), assessing patient understanding of treatments (35%), explaining risks and benefits of treatments (32%), and inquiring about patients’ treatment goals (23%). Based on these results, providers created action plans that included the development of standardized atopic dermatitis assessment templates for documentation and interprofessional workflows for SDM.

“Audit-feedback of SDM and quality of life measures can inform team-based initiatives to improve patient-centered [atopic dermatitis] care,” concluded Dr Codispoti, and colleagues.

EMR Tool Identifies Steroid Burden in Atopic Dermatitis and Asthma

Steroids are frequently prescribed for the treatment of atopic dermatitis and asthma. However, the cumulative burden associated with these medications is not routinely assessed by practitioners. Sonam Sani, MD, Allergy and Immunology Fellow, New York University Winthrop Hospital, Mineola, and colleagues set up to show how an electronic medical record (EMR) tool can be used to identify and track total steroid burden and associated side effects in patients with atopic dermatitis and asthma.2

The steroid-burden EMR tool was used to collect data on 99 encounters of atopic dermatitis (N = 58; 53% female; mean age, 31 years) and 64 encounters of asthma (N = 49; 63% female; mean age, 56 years) over an 18-month period.

Among the atopic dermatitis encounters, patients were using inhaled (N = 24), intranasal (N = 12), and systemic (N = 8) corticosteroids. Frequently reported side effects included pigment changes, skin atrophy, easy bruising, telangiectasia, striae, rosacea, and hair growth. There were 28 encounters that had an intervention, including decreased dose (N = 10), decreased potency (N = 3), and discontinuation (N = 15). Of the encounters, 86% documented patient counseling.

Among the asthma encounters, patients were using intranasal (N = 27) and systemic (N = 18) corticosteroids. Frequently reported side effects included candidiasis and hoarseness. There were 4 encounters that had an intervention, including decreased dose (N = 3) and discontinuation (N = 1). Of the encounters, 97% documented patient counseling.

“Using our EMR tool facilitates the identification and tracking of total [steroid burden] in patients, associated side effects, and leads to meaningful intervention,” Dr Sani and colleagues reported.

Standardized EMR Tool Helpful in Monitoring Side Effects Associated with Topical Corticosteroid Use

Topical corticosteroids (TCS) can be very effective in the treatment of atopic dermatitis. However, these medications can also cause side effects that need prompt interventions to improve QOL and patient outcomes. Daniel Maghen, MD, PGY2 Resident, New York University Winthrop Hospital, Mineola, and colleagues set out to discover whether the implementation of a standardized EMR tool would increase the documentation of TCS use in patients with atopic dermatitis, and whether this documentation would influence clinical practice.3

The researchers compared patient encounters before and after implementation of the EMR tool to assess the documentation of the following variables: TCS use, TCS potency, the development of any side effects, interventions, patient counseling, and patient satisfaction.

Before implementing the EMR tool, there were 172 encounters unique to 21 patients, whereas after implementation, there were 47 encounters unique to 21 patients. In addition, prior to implementation of the EMR tool, potency of TCS, and daily and weekly usage were recorded in 29.6%, 4.6%, and 20.5% of encounters, respectively. These percentages increased 100% for all variables following implementation of the tool. Documentation of other variables also increased, including side effects (8.3% vs 95.7%), interventions (2.3% vs 87.2%), counseling (4.6% vs 80.9%), and patient satisfaction (2.3% vs 78.7%).

“Implementation of a standardized EMR tool can allow for safe use of TCS in the treatment of [atopic dermatitis] while effectively monitoring for side effects and allowing for appropriate and timely intervention,” Dr Maghen and colleagues concluded.

Eosinophils Predict Severity of Atopic Dermatitis

The identification of biomarkers that are associated with more severe atopic dermatitis can be used to develop more effective treatments. Raissa Roque, Federal University of Sao Paulo, Brazil, and colleagues conducted a cross-sectional study with retrospective analysis to evaluate the clinical profile and allergic sensitization of patients with atopic dermatitis, and to determine which biomarkers may affect patient outcomes.4

The researchers analyzed data from medical charts of 110 patients (63.6% male; mean age 10.4 years) with atopic dermatitis. Among these patients, 76.3% had mild disease, 16.3% had moderate disease, and 7.4% had severe atopic dermatitis. Comorbidities included allergic rhinitis (90.9%), asthma (52.7%), ocular allergy (31.8%), food allergy (17.3%), and eosinophilic esophagitis (1.8%).

They found a significantly higher eosinophil count among patients with more severe atopic dermatitis, although no association was found for immunoglobulin E values and disease severity. Among patients with severe atopic dermatitis, 65% were polysensitized, whereas 25% of patients with mild disease had multiple sensitizations.

“The number of eosinophils was a predictor of severity in this sample. The presence of multimorbidity is remarkable, especially regarding respiratory diseases,” noted Dr Roque and colleagues. Patients with severe atopic dermatitis have higher eosinophil counts and a higher frequency of polysensitization, the researchers reported.

Age of Onset and Persistence of Atopic Dermatitis Predict Subsequent Disease Development

This progression from atopic dermatitis to sensitization to aeroallergens and then asthma can be described by the term “atopic march.” Atopic march is characterized by a sequence of atopic diseases in childhood, typically with atopic dermatitis predating the development of other allergic disorders later in life.

Mohamed Taki, MD, PGY4 Fellow, Allergy, Immunology & Rheumatology, Department of Pediatrics, Wisconsin School of Medicine and Public Health, Madison, and colleagues sought to investigate the relationship between atopic dermatitis phenotypes and the subsequent development of allergic diseases in childhood.5

The Childhood Origins of Asthma (COAST) clinical trial enrolled 250 children at birth and followed them prospectively. Annual questionnaires and diagnosis reports were used to assess atopic dermatitis, food allergy, allergic rhinitis, and asthma.

Latent class analyses identified atopic dermatitis phenotypes, including none/intermittent, late onset, and persistent. Persistent atopic dermatitis was significantly associated with an increased risk for allergic rhinitis and food allergy at age 6 years. Persistent and late-onset atopic dermatitis were significantly associated with an increased risk for asthma at 6 years of age.

“Our analyses suggest that both the age of onset and persistence of [atopic dermatitis] impact its association with the development of other allergic diseases,” the researchers reported. “Identifying mechanisms that underlie these associations may provide insight into personalized strategies towards allergic disease prevention.”

References

  1. Codispoti C, Mosnaim G, Lio P, et al. Real-world practices and perceptions regarding shared decision-making and patients quality of life among allergy and dermatology teams in two large US healthcare systems. J Allergy Clin Immunol. 2020;145(Issue 2; Suppl). Abstract 169.
  2. Sani S, Banta E, Mahirt S, et al. Utility of an EMR-tool to monitor total steroid burden in patients with atopic dermatitis and asthma. J Allergy Clin Immunol. 2020;145(Issue 2; Suppl). Abstract 179.
  3. Maghen D, Sani S, Noor I, et al. Topical corticosteroid documentation in atopic dermatitis pre- and post-implementation of an EMR tool. J Allergy Clin Immunol. 2020;145(Issue 2; Suppl). Abstract 622.
  4. Roque R, Moraes M, Marino L, et al. Which biomarkers in atopic dermatitis (AD) can be used in real life? J Allergy Clin Immunol. 2020;145(Issue 2; Suppl). Abstract 631.
  5. Taki M, Lee K, Gern J, et al. Atopic dermatitis phenotypes and the subsequent development of atopic diseases in a high-risk birth cohort. J Allergy Clin Immunol. 2020;145(Issue 2; Suppl). Abstract 634.

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