INTRODUCTION
Atopic dermatitis (AD) places a financial and illness burden on children and adults and is the most common chronic inflammatory skin disease.1 In July of 2023, the American Academy of Dermatology (AAD) released carefully crafted, evidence-based AD treatment guidelines providing strong recommendations for moisturizers, topical calcineurin inhibitors (TCIs), topical corticosteroids (TCS), topical phos-phodiesterase (PDE)-4 inhibitors, and topical Janus kinase (JAK) inhibitors.2 The guidelines also included conditional recommend- ations encouraging bathing and wet wrap therapy while avoiding topical antimicrobials, antiseptics, and antihistamines.3 While these interventions address the multifactorial etiology of AD, including immune system hyperreactivity and epidermal dysfunction contributing to the disease, they may also be complex, impractical, and counterproductive.1,3
The TCS recommended in the guidelines are effective for treating AD, providing rapid symptomatic resolution, especially in acute flares.2 However, some patients may not be optimal candidates for TCS. Although full-body application of TCS may benefit hospitalized patients with extensive disease, this regimen is impractical for daily use in moderate-to-severe AD. Patients or their caretakers are responsible for maintaining topical treatment in an outpatient setting, unlike in an inpatient environment, where trained personnel apply therapies at scheduled intervals. The large amount of time and the application frequency associated with widespread topical use inconvenience patients and may contribute to medication non-adherence.8 Other contributing factors to non-adherence include concern about the potential adverse effects of medications, limited patient education, forgetfulness, and provider mistrust.8 Adherence to AD treatment regimens also varies over time. In just the first three days of medication initiation, there is a 60% decline in the application of TCS therapy.9 Furthermore, patients frequently do not fill prescriptions for AD treatments; in other conditions, patients were less likely to fill two prescriptions than to fill a single prescription.10
The updated guidelines also emphasize lifestyle modifications such as wet wrap therapy and bleach baths to supplement additive treatments. However, it is challenging to achieve adherence to even a single treatment, much less to broad lifestyle changes. For example, among adult patients with hypertension, four out of five are aware of the benefits of lifestyle modification. Still, only one in five adhere to non-pharmacologic lifestyle modifications such as dietary changes.4 The use of pharmacologic interventions is higher but still disappointing, with less than half of patients with type 2 diabetes or hypertension taking their respective medications as prescribed.5,6
Moreover, AD treatments impose a financial burden on patients. The guidelines conditionally recommend using emollients, which are not typically covered by insurance. Assuming 1.5 grams can treat approximately 3% of body surface area (BSA), a single full-body application would require at least 45 grams. Over one month, patients would use 1,350 grams of moisturizer for treatment. If the average price of a moisturizer is $0.94 for 45 grams, this equates to approximately $338.40 per year spent on moisturizer.11,12 Consequently, this shifts costs to patients, disproportionately affecting those with lower socioeconomic status.
Regimen complexity is another concern for non-adherence. The current guidelines advise daily topical (prescription or non-prescription) applications for moderate-to-severe or recalcitrant AD. However, patients are less likely to adhere to this regimen than a single topical application daily, potentially eschewing treatment altogether due to overwhelming complexity. In other words, while applying multiple topical therapies is attractive in theory to target different aspects of AD pathophysiology, this strategy risks non-adherence, effectively failing to address any aspects of pathophysiology in practice.
The TCS recommended in the guidelines are effective for treating AD, providing rapid symptomatic resolution, especially in acute flares.2 However, some patients may not be optimal candidates for TCS. Although full-body application of TCS may benefit hospitalized patients with extensive disease, this regimen is impractical for daily use in moderate-to-severe AD. Patients or their caretakers are responsible for maintaining topical treatment in an outpatient setting, unlike in an inpatient environment, where trained personnel apply therapies at scheduled intervals. The large amount of time and the application frequency associated with widespread topical use inconvenience patients and may contribute to medication non-adherence.8 Other contributing factors to non-adherence include concern about the potential adverse effects of medications, limited patient education, forgetfulness, and provider mistrust.8 Adherence to AD treatment regimens also varies over time. In just the first three days of medication initiation, there is a 60% decline in the application of TCS therapy.9 Furthermore, patients frequently do not fill prescriptions for AD treatments; in other conditions, patients were less likely to fill two prescriptions than to fill a single prescription.10
The updated guidelines also emphasize lifestyle modifications such as wet wrap therapy and bleach baths to supplement additive treatments. However, it is challenging to achieve adherence to even a single treatment, much less to broad lifestyle changes. For example, among adult patients with hypertension, four out of five are aware of the benefits of lifestyle modification. Still, only one in five adhere to non-pharmacologic lifestyle modifications such as dietary changes.4 The use of pharmacologic interventions is higher but still disappointing, with less than half of patients with type 2 diabetes or hypertension taking their respective medications as prescribed.5,6
Moreover, AD treatments impose a financial burden on patients. The guidelines conditionally recommend using emollients, which are not typically covered by insurance. Assuming 1.5 grams can treat approximately 3% of body surface area (BSA), a single full-body application would require at least 45 grams. Over one month, patients would use 1,350 grams of moisturizer for treatment. If the average price of a moisturizer is $0.94 for 45 grams, this equates to approximately $338.40 per year spent on moisturizer.11,12 Consequently, this shifts costs to patients, disproportionately affecting those with lower socioeconomic status.
Regimen complexity is another concern for non-adherence. The current guidelines advise daily topical (prescription or non-prescription) applications for moderate-to-severe or recalcitrant AD. However, patients are less likely to adhere to this regimen than a single topical application daily, potentially eschewing treatment altogether due to overwhelming complexity. In other words, while applying multiple topical therapies is attractive in theory to target different aspects of AD pathophysiology, this strategy risks non-adherence, effectively failing to address any aspects of pathophysiology in practice.
