Trends in Atopic Dermatitis Management: Comparison of 1990-1997 to 2003-2012
February 2018 | Volume 17 | Issue 2 | Original Article | 135 | Copyright © 2018
Alice He BS,a Steven R. Feldman MD PhD,a,b,c and Alan B. Fleischer Jr. MDd
aCenter for Dermatology Research, Department of Dermatology, Wake Forest School of Medicine, Winston-Salem, NC bDepartment of Pathology, Wake Forest School of Medicine, Winston-Salem, NC cDepartment of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC dDepartment of Surgery, University of Kentucky College of Medicine, Lexington, KY
BACKGROUND: Atopic dermatitis (AD) is primarily treated with topical therapies, systemic immunosuppressants, or adjunctive therapies. OBJECTIVE: As novel treatment approaches for AD emerge, we characterize AD treatment and examine trends in treatment over time. METHODS: Visits for AD were identified in the 2003-2012 National Ambulatory Medical Care Survey (NAMCS). We identified topical corticosteroids (TCS), antibiotics (Abx), antihistamines (AH), topical calcineurin inhibitors (TCI), and systemic immunosuppressants (SI) prescribed at AD visits. RESULTS: There were 990,000 annual visits for AD from 2003-2012 (3.2 visits/1000 people/year). TCS were the most frequently used medication (59% of visits). Topical calcineurin inhibitors (TCI) were the second most prescribed medication for AD among dermatologists (23% of visits), while antihistamines were second among all other physicians (16-44% of visits). Unlike other medications, use of TCIs decreased over time. LIMITATIONS: The NAMCS does not follow individual patients over time. CONCLUSIONS: TCI use has been decreasing. New topical AD treatments may provide an alternative to TCS, better treatment outcomes for moderate-to-severe atopic dermatitis, and an alternative to systemic antihistamines whose efficacy in AD is unproven and whose general use in AD management is discouraged by the American Academy of Dermatology. J Drugs Dermatol. 2018;17(2):135-140.
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Atopic dermatitis (AD) is a common inflammatory skin condition characterized by xerosis, lichenification, and eczematous lesions with severe itch. As there is no cure for this disease, the majority of therapy used to manage AD is limited towards symptomatic control and restoration of the disrupted skin barrier. Topical corticosteroids (TCS) have been the mainstay of AD therapy for decades.1,2 Topical calcineurin inhibitors (TCI) were introduced in 2000 as an alternative to TCSs, with claims that they were equally as efficacious as TCSs but without the side effect of cutaneous atrophy commonly feared with extended TCS use.3,4 When topical treatments fail, providers often resort to systemic immunosuppressants to control inflammation, including systemic steroids, cyclosporine, methotrexate, and mycophenolate mofetil. Their use, however, is limited due to concern for their toxic side effect profiles and suboptimal risk-benefit ratios. Adjunctive therapies used in AD include antibiotics to treat bacterial super-infections and anti-histamines to disrupt the itch-scratch cycle.5,6 While these therapies are often sufficient to manage mild disease, their effect is only transient in patients with moderate or severe disease. There has been a recent surge in the number of clinical trials evaluating new treatment modalities for the management of moderate-to-severe AD.7,8 Interest is particularly strong for topical phosphodiesterase (PDE)-4 inhibitors and systemic biologic agents that target pathways central to AD pathogenesis.7,8 With the multitude of new treatments set to emerge for AD, we characterize how AD is currently being managed in order to determine how new agents may play a role in AD management in the future.We previously reported on the treatment of AD in the office-based setting using data from the National Ambulatory Medical Care Survey (NAMCS) from 1990-1997.9 Dermatologists and allergists used more complex topical corticosteroid regimens in the management of AD than did other physicians. Dermatologists also used higher-potency anti-inflammatory agents more frequently than other physicians.10 Horii et al used the same dataset to examine treatments for AD between 1997-2004 and found similar rates of TCS and TCI use for AD in the pediatric population.11 We update these results with more recent data to examine trends in AD management over time.
Data were compiled from the United States (US) National Ambulatory Medical Care Survey (NAMCS), which is an ongoing national