Undertreatment in adult patients with moderate‐to‐severe atopic dermatitis and other chronic inflammatory skin diseases

Undertreatment in adult patients with moderate-to-severe atopic dermatitis and other chronic inflammatory skin diseases In this issue of the Journal, Pascal et al. reports on a retrospective observational study performed in May 2017, using the electronic medical record of the Lyon-Sud University Hospital, in France. The objective of their study was to compare the therapeutic management of adults with atopic dermatitis (AD) with those with psoriasis and chronic urticaria (CU) in real-life setting. They found that a high proportion (i.e. 73%) of AD patients presented with a moderate-to-severe form of the disease compared to only 39% of CU and 17% of psoriasis patients. However, a systemic treatment was prescribed only in 8% of patients with AD compared to 26% and 47% of CU and psoriasis patients, respectively. They conclude that treatment of AD mostly relies on topical treatments with only a minority of moderate-to-severe cases in need receiving a systemic treatment. These results point to a significant under-use of systemic therapies in AD, compared to psoriasis and CU. Our first consideration is that the study reflects the scarcity of the therapeutic armamentarium labelled for moderate-to-severe AD before 2017, consisting in topical treatments and cyclosporine, that was significantly poor when compared with treatment options for psoriasis that included acitretin, methotrexate, cyclosporine, apremilast and three different classes of biologics (TNF-a, IL-12/23 and IL-17 inhibitors). Dupilumab was approved by the European Medicines Agency for moderate-tosevere AD in 2017. Indeed, the proportion of patients in the study treated with dupilumab was only 0.7% (three out of 401). We could easily speculate that nowadays this proportion would be significantly higher. Secondly, the study reflects therapeutic management of patients referring to one centre of Dermatology, that is, Lyon-Sud Hospital (France). It is likely that the management of AD with systemic medications such as cyclosporine, methotrexate, azatioprine or PUVA could had been different in other Dermatological centres. The use of systemic treatments is guided by national and international guidelines, but is also importantly based on local tradition. Also important, in the study by Pascal et al. the SCORAD index of AD patients was 37.8 20.3. In general, AD is considered moderate when the SCORAD is between 20 and 40 and severe when higher than 40 or 50. Therefore, a significant proportion of AD patients had mild or moderate disease. Surprisingly for a University Hospital centre, patients with psoriasis and CU included in the study had a low disease severity score with a PASI score of 6 6.6 and a UAS7 of 13.3 11.9, respectively. Accordingly, the impact on the quality of life (DLQI) was low or moderate in all three disorders. Undertreatment (i.e. a higher proportion of patients who are untreated and/or inadequately treated according to the disease severity and patient needs) is a very important issue for many disorders, including chronic inflammatory skin diseases. Undertreatment has been poorly investigated in AD patients. In contrast, several studies addressed the clinical relevance of undertreatment in patients with moderate-to-severe psoriasis. In particular, the Multinational Assessment of Psoriasis and Psoriatic Arthritis (MAPP) Survey analysed 3426 patients from 139 948 screened households and 781 physicians in North America and Europe. The study found that only 11% of patients with plaque psoriasis with body surface area greater than 10% and 37% of those with psoriatic arthritis were receiving systemic treatment, confirming a significant gap existing for the adequate treatment. The limiting factors for initiating systemic therapy were tolerability and long-term safety concerns in the case of conventional systemic treatments and cost, particularly for biologics. Moreover, based on our clinical experience, we could add that the management of patients with a chronic skin disorders such as AD or psoriasis, is not limited to the pure selection of the therapeutic agent, but is burdened by repeated interactions with very demanding patients as well as by the administrative procedures related to the drug prescription that may result in excessive workloads. In particular, communicating the nature of the disease (its genetics, chronic relapsing course, triggering factors, multifactorial nature, prognosis), instructing the patient on the proper use of topicals (emollients and topical drugs), communicating the characteristics (including pros and contras) of the systemic treatments and discussing the treatment options with patients and/or the general practitioner may represent a critical challenge to face in managing patients with moderate-to-severe AD and potentially in emotional exhaustion of the physicians. A patient-centred approach has been advocated as a best practice when caring for patients with chronic diseases such as AD, but it implies a very emotionally demanding interaction with patients that some physicians would prefer avoiding. Therapeutic educational programs may help in this regard, but they in turn may raise other issues including availability of time and dedicated physicians, possible disagreements between the caring and the instructing physician as well as the cost and insurance coverage.