Guidance for AD Management Refreshed With New Recommendations

Clinical care, future research, and practice guidelines from the American Academy of Allergy, Asthma & Immunology/American College of Allergy, Asthma and Immunology Joint Task Force on Practice Parameters may be informed by 6 themes that focus on patient values and preferences for atopic dermatitis (AD) treatment, following a new systematic analysis from a team of American and Canadian experts in the space.

High-, moderate-, and low-certainty evidence was considered in their systematic review of 62 studies covering 19,442 participants, found following reviews of MEDLINE, Embase, PsycINFO, and CINAHL from inception through March 20, 2022; the studies could be of any design and in any language. Most (n = 23; not including the United Kingdom) took place in Europe and were cross-sectional in nature (n = 28), and they all occurred between 1998 and 2021. The largest survey covered 3093 patients and the smallest, 9 patients. The findings were recently published online in JAMA Dermatology.

“These values and preferences can inform AD care,” the study authors wrote. “Systematic summaries of evidence addressing patient values and preferences have not previously been available.”

A strong patient-clinician relationship and improved treatment adherence (n = 24 studies; low-certainty evidence) was the most common theme identified, and it encompassed treatment demonstrations and instructions and strong verbal and written communication. All of these, the study researchers emphasized, can facilitate treatment adherence.

The second most common theme was fear and concern about adverse effects (n = 14 studies; moderate-certainty evidence), with the involved patients and their caregivers stressing their priority of wanting to balance the benefits of prescribed treatments with concerns about long-term chronic use. In particular, topical corticosteroids were cited for skin thinning stemming from continuous use.

A third theme identified was preferring treatments that minimally affect quality of life and activities of daily living (n = 12 studies; low-certainty evidence), and this itself contained the subthemes of effects on social interactions, ease/frequency of application, and treatment route—all of which circle back to the burden imposed by topical treatments. Psychological, mental, and emotional well-being were highlighted as suffering within this theme and its subdivisions.

Examples included having to make tough decisions of not seeing friends because you need to apply cream to control flares or, as was noted by pediatric patient caregivers, their children having to endure great treatment burden with topical therapies; they wished for age-appropriate treatments that would be easier to administer (ie, a spray instead of having to carry tubes of creams). Another hope is for oral or injectable medications that do not require a daily dosing schedule, because these are less-invasive modes of delivery, according to the study participants.

Treatment preference to use topical corticosteroids for the shortest time allowable and then to control eczema flares was the fourth theme identified (n = 11 studies; low-certainty evidence). The participants underscored their wanting a treatment course that initiates when their disease is poorly controlled and that concludes when eczematous lesions are resolved. Some noted this was because topical corticosteroids can actually aggravate the AD if used incorrectly.

Relief from itching or burning skin sensations (n = 9 studies; low-certainty evidence) was the fifth identified theme, with patients noting they understand immediate clear-up of flares is not possible, but they would like immediate relief from eczema’s accompanying itching and burning.

The sixth theme identified was initiating treatment with nonprescription methods (n = 6 studies; high-certainty evidence). With this preference, the study authors noted that patients expressed a “lower risk of adverse effects associated with nonprescription medications as compared with a perception of greater efficacy of prescription medications.” However, patients also still expressed wanting to step up therapy according to disease flares.

The investigators of this review stressed their desire for these 6 themes to inform eczema care moving forward, noting the concerns of patients and their caregivers related to treatment and its effects on daily living and quality of life, as well their wanting to trust the care plan laid out by their health care providers.

“Our findings of the need for information surrounding the practical issues related to treatments, such as applying topicals, are also consistent with the experience of patients with conditions such as cardiovascular disease and chronic pain,” they wrote. “Future studies should clearly report whether patient values and preferences are affected by AD severity. Together, the residual uncertainty regarding these treatments encourages individualized patient care through shared decision-making.”

Reference

Maleki-Yazdi KA, Heen AF, Zhao IX, et al. Values and preferences of patients and caregivers regarding treatment of atopic dermatitis (eczema): a systematic review. JAMA Dermatol. Published online January 25, 2023. doi:10.1001/jamadermatol.2022.6045