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Recent Research to Consider in the Treatment of Atopic Dermatitis and Eczema

Recent Research to Consider in the Treatment of Atopic Dermatitis and Eczema

Research continues to explore more therapeutic options for the treatment and management of eczema, including atopic dermatitis (AD), contact dermatitis, and seborrheic dermatitis. Of the more than 900 ePosters displayed at the American Academy of Dermatology Virtual Meeting Experience 2020, 74 ePosters and 13 ePosters filled the AD and dermatitis (contact, allergic, and irritant) categories, respectively. While many of the eposters highlighted the results of clinical trials, there were a significant number that assessed various nontherapeutic aspects of care for patients with AD: physician decision-making and evaluation,1 comorbidities,2,3 and patient quality of life.4-6 These are a few of the studies that may have an impact on your patient care.

Top-selling Consumer Moisturizers Contain Allergens
Researchers from the University of Arizona analyzed the allergenic potential, ingredients, marketing claims, and pricing of eczema7 and facial8 moisturizers, finding that a majority of the best-selling moisturizers contain at least one allergen in its ingredients. The results are notable when the product marketing is considered, emphasizing the need for dermatologists to educate patients with AD and eczema on potential ingredient triggers for flareups.

For eczema moisturizers, the research group compiled lists of the top 30 best-selling products for the condition from Target, Walmart, and Amazon.7 Using the rankings of the three lists to make one average top 30 list, they then analyzed each product for its ingredients, customer rating, pricing, and marketing claims. The American Contact Dermatitis Society Contact Allergen Management Program was used to determine the allergenic potential of each product. The potential, price, and average customer rating were compared with the marketing language of each product, with key descriptors such as eczema relief, dermatologist-recommended/approved, sensitive skin/gentle, and anti-itch.

In total, the study found 28 of the 30 best-selling eczema moisturizers contained at least one allergen. Cetyl alcochol, an emulsifier and stabilizer, was found in 21 products. It was followed by phenoxyethanol (n=15), a preservative, and aloe (n=10), an anti-inflammatory. Rounding out the most common allergens in this product group were benzyl alcohol (n=9), panthenol (n=8), ethylenediaminetetraacetic acid (EDTA; n=7), mineral oil (n=7), tocopherol (n=6), benzalkonium chloride (n=4), chamomile (n=3), and stearyl alcohol (n=3). 

A similarly constructed study for the top 100 best-selling facial moisturizers found comparable results.8 Of this product group, EDTA was identified in 62 of 100 products, phenoxyethanol in 57, and cetyl alcohol in 43. The rest of the top 10 allergens in this product group included fragrance (n=36), panthenol (n=31), avobenzoate (n=26), steatyl alcohol (n=26), benzoate (n=22), butylated hydroxytoluene (n=22), and aloe (n=18). Common marketing phrases included natural, fragrance-free, expert-approved, age preventing, sensitive skin, and SPF. A statistically significant relationship existed between the marketing labels of expert-approved and SPF and the average number of allergens per product.

Both studies underline the important role dermatologists must fulfill. Patients with truly sensitive skin, such as those with AD, should be informed of potential allergenic triggers. Dermatologists should aid patients in selecting products appropriate for their skin needs.

Differences Found Between Pediatric Patients With AD vs Eczema 
Though AD and eczema are often used interchangeably, the literature has not established any synonymous relationship between the two terms. A research group sought to explore the patient groups diagnosed with these conditions through a retrospective review of electronic health record data, and they found a number of statistically significant differences in patient characteristics, disease severity, and treatments.9

Using deidentified EHR from January 1, 2016, to June 30, 2018, the study included patients aged 2 to 17 years with a clinical diagnosis of AD or eczema based on International Classification of Diseases codes. Data extracted included patient characteristics (age, gender, race, geographic region, comorbidities), disease severity based on 6-point Investigator’s Global Assessment (IGA) for AD and 7-point IGA for eczema, and prescribed AD-related treatments at index date. Patients were excluded if they had a diagnosis of AD and eczema.

A total of 79,134 and 187,165 patients with AD and eczema, respectively, were identified from the EHR. Patients with AD were a mean age of 9.1 years, 56.5% female (43.5% male), and a majority unknown racial background (43.5%; white, 36.9%; African American, 9.0%; Asian, 4.2%; other, 6.3%). Comparatively, patients with eczema were a mean age of 10.6 years, 57.2% female (42.8% male), majority white (unknown race, 36.6%; African American, 8.0%; other, 5.6%; and Asian, 5.6%). Patient comorbidities included allergic contact dermatitis (96.9% eczema vs 60.4% AD), asthma (17.2% eczema vs 18.9% AD), pruritus (14.5% eczema vs 17.3% AD), allergic rhinitis (11.4% eczema vs 12.3% AD), and skin/subcutaneous tissue infection (11.1% eczema vs 10.4% AD). 

Further, the two cohorts differed in clinical characteristics. Mean body surface area (BSA) score was 22.5 vs 15.9 and mean pruritus score was 4.3 vs 3.0 in the AD vs eczema cohorts, respectively. Of the AD cohort, 9.8% reported IGA 4 and 1.2% reported IGA 5 vs only 4.4% for IGA 5 and 1.1% for IGA 6 in the eczema cohort. Treatments varied sometimes significantly. Patients with AD were more often treated with systemic therapies with or without topical therapies (6.1%), whereas the eczema group only used systemic therapies in 3.5%. 

When considering the whole dataset, the authors found differences in baseline characteristics. Given that increased disease severity was observed in the AD group, the authors concluded physicians may diagnose AD for more severe presentation. 

New Assessment Tool Simplifies Pediatric AD Severity
A critical component to evaluating treatment effectiveness and patient outcomes are disease severity assessment tools. While the Eczema Area and Severity Index (EASI) is recommended as an outcome measure for severity assessment, it can be complicated for the investigator and inapplicable for clinical use. A new IGAxBSA tool, akin to the PGAxBSA tool for psoriatic disease severity, was found to be a quick, simple, and easy alternative to EASI for the measurement of disease severity in pediatric AD.10

To evaluate the clinical efficacy of IGAxBSA, 195 caretaker/child pairs were recruited to participate. Patient demographics and medical history, AD-related characteristics, and patient-reported outcomes were recorded using validated IGA (vIGA), BSA, EASI, SCORing Atopic Dermatitis (SCORAD), Patient Oriented Eczema Measure (POEM), Children’s Dermatology Life Quality Index (CDLQI), and Itch Numerical Rating Scale (NRS). Data for IGAxBSA and EASI were then visually analyzed by scatterplot and Bland-Altman plot. IGAxBSA (score range, 0-400) was rescaled by a constant factor of 5.556 to create a score more comparable to EASI.

Of the 195 participants, 41.5% were male with a mean age of 10.3 years at study enrollment, mean IGA score of 3.0, mean SCORAD score of 47.0, mean POEM score of 14.5, mean CDLQI score of 9.5, and mean IGAxBSA score of 92.2. IGAxBSA was found to correlate significantly more strongly with EASI than vIGA alone, and a similar strength of correlation with SCORAD was seen as well. The authors noted that IGAxBSA score also correlated with POEM, Itch NRS, and CDLQI, but these correlations were not as strong as that with EASI and SCORAD.

In addition, this study established a severity strata for IGAxBSA through an EASI-anchor-based approach. Possible severity thresholds were determined through the correspondence between mean, median, and mode EASI score and EASI threshold values. IGAxBSA strata consisted of mild (0-30), moderate (30.1-130), and severe (130.1-400). 

The study investigators proposed that IGAxBSA could be used as a quick, easy-to-interpret disease severity scoring system.


References
1. Lio PA, Mosnaim GS, Codispoti C, et al. Chart-based assessment of AD treatment decision-making among dermatology and allergy teams in two health care systems. Presented at: American Academy of Dermatology Virtual Meeting Experience 2020; June 12-14, 2020. Accessed June 25, 2020. https://eposters.aad.org/posters/18008/18008.pdf

2. Yousaf M, Ayasse M, Ahmed A, et al. The association between atopic dermatitis and hypertension: a systematic review and meta-analysis. Presented at: American Academy of Dermatology Virtual Meeting Experience 2020; June 12-14, 2020.
Accessed June 25, 2020. https://eposters.aad.org/posters/18856/18856.pdf

3. Patel KR, Yousaf M, Lee HH, et al. A systematic review and meta-analysis investigating the association between atopic dermatitis and anxiety. Presented at: American Academy of Dermatology Virtual Meeting Experience 2020; June 12-14, 2020. Accessed June 25, 2020. https://eposters.aad.org/posters/15351/15351.pdf

4. Kwatra SG, Huang AH, Jhaver MB, Gruben D, Fung S, DiBonaventura M. Health status, work productivity, and health care resource utilization (HCRU) in patients with moderate-to-severe atopic dermatitis (AD): analysis of the 2017 US National Health and Wellness Survey (NHWS). Presented at: American Academy of Dermatology Virtual Meeting Experience 2020; June 12-14, 2020. Accessed June 25, 2020. https://eposters.aad.org/posters/16434/16434.pdf

5. Barbarot S, Silverberg JI, Gadkari A, et al. The family impact of atopic dermatitis (AD) in children aged 6-11 years: a cross-sectional study in the United States, Canada, Europe, and Japan. Presented at: American Academy of Dermatology Virtual Meeting Experience 2020; June 12-14, 2020. Accessed June 25, 2020. https://eposters.aad.org/posters/15021/15021.pdf

6. Silverberg JI, Gruben D, Smith TW, Fung S, Myers DE. The economic burden of mild-to-moderate atopic dermatitis (AD) in the United States: analyses of the National Health and Wellness Survey (NHWS). Presented at: American Academy of Dermatology Virtual Meeting Experience 2020; June 12-14, 2020. Accessed June 25, 2020. https://eposters.aad.org/posters/16889/16889.pdf

7. Chan A, Thompson A, Kromenacker B, et al. Allergenic potential, ingredients, marketing claims and pricing of eczema moisturizers. Presented at: American Academy of Dermatology Virtual Meeting Experience 2020; June 12-14, 2020. Accessed June 26, 2020. https://eposters.aad.org/posters/17935/17935.pdf

8. Thompson AM, Kromenacker B, Loh TY, Segal R, Shi VY. Allergenic potential, marketing claims and pricing of facial moisturizers. Presented at: American Academy of Dermatology Virtual Meeting Experience 2020; June 12-14, 2020. Accessed June 26, 2020. https://eposters.aad.org/posters/14139/14139.pdf

9. Boytsov NN, Goldblum OM, Gorritz M, et al. Patients’ characteristics and treatment strategies in pediatric patients diagnosed with atopic dermatitis versus eczema – a real-world retrospective cohort study. Presented at: American Academy of Dermatology Virtual Meeting Experience 2020; June 12-14, 2020. Accessed June 26, 2020. https://eposters.aad.org/posters/15342/15342.pdf

10. Suh TP, Ramachandran D, Patel V, Rangel SM, Fishbein AB, Paller AS. IGAxBSA: a simple practice-friendly alternative to the Eczema Area and Severity Index (EASI) for assessing severity of pediatric atopic dermatitis. Presented at: American Academy of Dermatology Virtual Meeting Experience 2020; June 12-14, 2020. Accessed June 26, 2020. https://eposters.aad.org/posters/17030/17030.pdf

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