Practice Patterns Around the Management of Atopic Dermatitis in 2018 and 2020

Atopic dermatitis (AD) is a chronic, relapsing and remitting inflammatory skin condition. Our group of 17 Canadian AD experts published a consensus document of recommendations for the assessment and management of adult patients with AD ¹ . Before and after the release of this document, the lead authors conducted a survey to identify practice gaps and educational needs related to AD. Questionnaires were sent via email to a Canadian sample of dermatologists, allergists, and primary care physicians (PCPs) with a focus on skin disease provided by Professional Targeted Marketing (ptm-health.com) at two separate time points (in 2018 and 2020). Participation was voluntary, uncompensated, and anonymous.

A total of 202 participants responded to the surveys, 131 in 2018 and 71 in 2020. Most respondents were dermatologists, with an average of over 15 years of clinical practice and 30 AD patients seen per month (Supplemental Table S1). Overall, there was agreement between clinical practice and recommendations on AD management (Supplemental Tables S2, S3), however some educational gaps persist. With regards to assessment of AD, most surveyed dermatologists and several consensus documents ^2,3 suggest a Body Surface Area (BSA) score of ≥10% and a Physician Global Assessment (PGA) ≥ 3 to define moderate-to-severe disease. PCPs perspectives on disease severity strata were more diverse, suggesting a potential need for education around assessment tools. The lack of a unified view on severity strata for AD in the available literature may limit proper assessment of moderate-to-severe disease. ^1,2 Dermatologists reported less BSA use in 2020 than in 2018, while EASI use increased, possibly due to initiation and reimbursement criteria for certain biologic therapies (Supplemental Figure S1). To assess patient well-being or QoL, most respondents used ‘overall patient satisfaction on therapy’, while very few used formal patient-reported outcomes (PROs) such as the recommended Patient-oriented Eczema Measure (POEM) which also captures sleep disturbance and patient-reported itch ¹ (Supplemental Figure S2). No respondents indicated using POEM in 2018, and only 3% of dermatologists used it in 2020.

For adults with moderate-to-severe AD uncontrolled with topical therapies, industry-sponsored consensus manuscripts ^2,3 have recommended the use of dupilumab as a first-line systemic treatment. The use of dupilumab to treat moderate-to-severe AD was reported more frequently by all specialty groups in 2020 than in 2018. The proportion of dermatologists who preferred dupilumab for their AD patients was higher than the proportion who actually prescribed it (83%, 45% in 2020), suggesting potential prescribing barriers that may be primarily due to specific provincial reimbursement restrictions (Supplemental Figure S3).

Interestingly, 50% of PCPs surveyed indicated they avoided using dupilumab in 2020 and almost 30% of PCPs indicated using systemic corticosteroids as their first-line systemic therapy of choice, suggesting areas where more education may be required (Supplemental Figure S3). Although systemic corticosteroids are approved by both the FDA and Health Canada for the treatment of moderate-to-severe AD, they should only be used for acute severe exacerbations, and in short courses as a bridge to steroid-sparing immunosuppressants due to concerns with toxicity, long term side effects, and disease relapse on cessation of treatment. ^{3 -5}