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Supplements Atopic Dermatitis: Focusing on the Patient Care Strategy in the Managed Care Setting
Overview of Atopic Dermatitis
Carmela Avena-Woods, BS Pharm, PharmD, BCGP
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Treatment and Managed Care Issues of Atopic Dermatitis
Danielle Ezzo, PharmD, BCPS
Atopic Dermatitis: Focusing on the Patient Care Strategy in the Managed Care Setting

Treatment and Managed Care Issues of Atopic Dermatitis

Danielle Ezzo, PharmD, BCPS
The specific cause of atopic dermatitis (AD) is not known. It is a multifactorial disease involving environmental agents, immune dysregulation, genetic predisposition, and defects in skin barrier function. Patients are typically classified as having mild, moderate, or severe disease. Most patients with AD can control their symptoms with various combinations of moisturizers, conventional prescription therapies, and lifestyle modifications, while patients with more severe disease may require adjunctive treatment with phototherapy, biologic treatments, or systemic immunosuppressants. As a result, patient-centered treatment plans are critical to patient care. The appropriate use of nonpharmacologic and pharmacologic treatment interventions combined with patient-specific written action plans could improve both patient health and medication outcomes.
Am J Manag Care. 2017;23:-S0
The etiology of AD is not well understood. Evidence suggests that AD is a multifactorial disease involving environmental agents, immune dysregulation, genetic predisposition, and defects in skin barrier function.1 Diagnosis of AD is complicated by variability in clinical presentation and the lack of consensus surrounding diagnostic criteria.2 Patients are typically classified as having mild, moderate, or severe disease. The majority of patients can control AD symptoms with various combinations of moisturizers, conventional prescription therapies, and lifestyle modifications. Patients with more severe disease may require adjunctive treatment with phototherapy, biologic treatments, or systemic immunosuppressants. Consequently, accurate diagnosis and individualized patient-centered treatment plans are critical to patient care.

Nonpharmacologic Interventions
Topical Moisturizers and Prescription Emollient Devices
Maintaining skin hydration and preventing transepidermal water loss (TEWL) are essential components of AD treatment. Over-the-counter (OTC) topical moisturizers are applied to the skin to prevent dryness and TEWL. Studies show that the application of topical moisturizing agents alone reduces symptom severity3,4 as effectively as topical corticosteroids (TCSs) used in patients with AD.5 In a 3-week study involving children with mild-to-moderate AD, the application of desonide 0.05% every other day plus 2% sunflower oil twice daily was as effective as once- or twice-daily desonide alone (P = .83).6 The properties and composition of topical moisturizers can vary greatly, making a given product more or less suitable for an individual. Traditional agents contain varying amounts of the following: 1) emollients that soften skin by filling in spaces between desquamating corneocytes; 2) occlusive agents that create a hydrophobic film on the surface of skin to prevent TEWL; and 3) humectants that attract and retain water from the deeper dermis.7 Topical moisturizers are available as oils, lotions, creams, ointments, and gels. Lotions often contain preservatives and fragrances, which can function as irritants to the skin; they also have a high water content, which creates an additional drying effect. Ointments have the advantage of generally being preservative free; however, cosmetic acceptability of ointments is a concern due to their greasy texture and may inhibit adherence.8 As a result, the following factors must be taken into consideration when helping patients and caregivers select a topical moisturizer: ease of application, how it smells, how well it is absorbed, and how it feels on the skin.9 Regardless of the particular product and delivery system that is used, the selected moisturizer must be one that the patient feels comfortable using on a daily basis, given our current understanding of barrier dysfunction in the pathogenesis of AD. Topical moisturizers enhance the hydration of the skin and minimize flare-ups and complications of AD. Therefore, they are considered an integral component of the maintenance plan. Application should be individualized for patients and can range from daily to multiple applications in a day. Topical moisturizers are best when applied soon after bathing to optimize skin hydration.8,10

In addition to topical moisturizers, prescription emollient devices (PEDs) are used to prevent TEWL and to improve skin hydration in patients with AD. PEDs are different from OTC moisturizers in that they are FDA-approved, 510(k) devices that provide a structural role in skin barrier function; they do not exert their effects by any chemical actions.8 They are generally applied to the skin 2 to 3 times daily depending on the specific agent. Comparative studies evaluating the cost-effectiveness of PEDs and OTC moisturizers have produced mixed results.11,12 In an investigation of treatment cost, a total of 39 patients aged 2 through 17 years with mild-to-moderate AD were randomized to receive 1 of the following treatments: glycyrrhetinic acid containing PED, ceramide-dominant PED, or OTC petrolatum-based topical moisturizer. Patients were instructed to apply the study treatment 3 times daily for 21 days. No significant between-group differences were observed at days 7 or 21, but OTC petrolatum-based moisturizer was nearly 50 times more cost-effective than either PED.12

Notably, head-to-head trials comparing specific topical moisturizing agents are limited. As a result, the selection of moisturizing agents is highly dependent on patient preference and cost. There is no published guidance on the correct order of application of moisturizers and prescription AD treatments. One study showed that the order of TCSs and moisturizers did not matter as far as influencing severity of disease.13 Product labeling of topical calcineurin inhibitors (TCIs) indicates that moisturizers may be applied after use.14,15



 
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