Consensus for the treatment of atopic dermatitis in primary care: resolving myths and legends based on evidence

Background: Atopic dermatitis is a chronic relapsing-remitting dermatosis commonly presented in primary healthcare facilities. Although there is no cure for atopic dermatitis, early diagnosis, and appropriate treatment are essential in the management of atopic dermatitis and in preventing its complications. Primary healthcare physicians are the first to encounter most patients with atopic dermatitis; hence, correct practices and knowledge of atopic dermatitis are important among primary healthcare physicians. This study aims to assess the knowledge and practice of primary healthcare physicians concerning diagnosing and treating patients with atopic dermatitis. Methods: A cross-sectional study was conducted among primary health care physicians working at governmental primary health centers in Bahrain to determine the knowledge, attitudes, and practices towards atopic dermatitis. In addition, a self-administered online questionnaire was distributed among the participants using online surveys. Results: A total of two hundred and eighty (n=280) primary healthcare physicians were recruited (response rate 80%). The average knowledge score (correct answers) was 46.7 ± 14.0 out of 100. Being a general practitioner (P<0.002), having more years of experience (P=0.044), and being of older age (P=0.003) were significantly associated with a lower knowledge score. The study also showed a wide range of varying practices among participants in managing patients with atopic dermatitis. Conclusion: There were significant variations in the knowledge and practice amongst primary care physicians towards atopic dermatitis that could delay the treatment of the condition and, therefore, possibly decrease treatment adherence. Conducting targeted educational interventions and developing strategies by dermatologists could minimize such gaps in practice and knowledge.

Family Physicians Sue to Shine Light on RUC Deliberations, Claim Specialists Skew Reimbursement Against Primary Care

IntroductionThe diagnosis and management of atopic dermatitis (AD) is extensively addressed in detailed clinical guidelines. However, the high heterogeneity regarding presentation and progression and the increasingly broad therapeutic landscape suggest a complex real-world scenario, leading to multiple trajectories of AD patients.MethodsUsing a Delphi methodology for assessing the degree of consensus, we explored the views of a panel of dermatologists regarding the patients’ trajectory through the diagnosis (block 1), treatment (block 2), and long-term management (block 3) of AD. Based on a systematic search of the literature, a scientific committee prepared a questionnaire of relevant items that were rated on a 10-point scale (from “totally agree” to “totally disagree”) by a panel of dermatologists attending patients with AD in the hospital setting. Consensus was established based on predefined rules.ResultsThe final questionnaire included 58 items and was answered by 17 dermatologists. Overall, consensus was reached on 22 items (37.9%), each of which was a consensus for agreement. The consensus rates in blocks 1, 2, and 3 were 22.7%, 19.0%, and 86%, respectively.ConclusionsOur analysis revealed a remarkable lack of consensus on various aspects of the routine diagnosis and treatment of AD. These findings suggest the presence of unmet needs or limited implementation of guidelines for the management of AD and encourage further research to explore the causes of this low consensus on the management of AD in the real-world setting.Supplementary InformationThe online version contains supplementary material available at 10.1007/s13555-021-00592-y.

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Relevance. Atopic dermatitis (AD) is a common multifactorial disease in which allergens from the yeast Malassezia can worsen the severity of the disease. Local application of antimycotic drugs can reduce the allergen load on the skin and improve its condition. Objective: The aim of this study was to evaluate the effectiveness of ketoconazole 2% cream in the treatment of AD in children as an additional therapy, and the effect of sensitization to Malassezia and polymorphism rs7309123 in the Dectin-1 gene on the effectiveness of treatment. Materials and methods. 54 patients with atopic dermatitis aged 6-18 years were included in the study. Patients were randomized into two groups: a group receiving ketoconazole cream 2% (n=28) and a control group (n=26). Specific IgE to Malassezia was analyzed in 28 patients of the main group. Genotyping of the rs7309123 polymorphism in the Dectin-1 gene was performed in a group of patients using real-time PCR. Atopic dermatitis disease activity was evaluated before and after treatment using the SCORAD. Results. Improvement was observed in both groups of children in 3 weeks after treatment (p<0,001). Children who received ketoconazole in addition to therapy had significantly better dynamics of the severity indicator, compared to the control group (W=465,0, p<0,001). The rs7309123 polymorphism in the Dectin-1 gene affected the effectiveness of treatment: ΔSCORAD in the subgroup of children with the CC and CG genotypes was significantly higher than in the subgroup of children with the pathological GG genotype (20,2±11,5 and 13±6,5, respectively, T=2,12, p=0,044). Conclusion. This study demonstrated the effectiveness of ketoconazole in the treatment of atopic dermatitis as an additional therapy.

Atopic dermatitis (AD) has significant negative impact on health-related quality of life, mood, sleep, work productivity and everyday activities. Research into the use of new drugs in the management of AD continues to develop, and international updates and recommendations have been published. However, questions remain in the Australian setting. This consensus aims to provide evidence-based insights and practical advice on the management of adult AD in Australia. A panel (five dermatologists and one clinical immunologist) met to review the literature, critically examine clinical questions of relevance to Australian healthcare practitioners and develop a series of recommendation statements. A consensus panel, comprising the initial panel plus nine additional members, used a 2-round Delphi voting process to determine a set of final guidance statements. ≥75% agreement in the range 7-9. Round 1 voting comprised 66 guidance statements. Of these, consensus was reached on 26, which were retained, and five were removed. The remainder (35) were modified and one new guidance statement was added for inclusion in round 2 voting. After round 2, consensus was reached on 35, which were retained, and one was removed (considered redundant). The 61 guidance statements upon which consensus was reached were then used to support a series of core consensus recommendations and a management flow chart. Expert consensus recommendations providing practical guidance of clinical relevance to specialists and primary care physicians in Australia have been developed. Dissemination of this guidance and evaluation of its impact on patient outcomes remain to be undertaken.

British Journal of Community NursingVol. 21, No. 2 CommentUse of emollients in the management of atopic eczemaShelley PeacockShelley PeacockSearch for more papers by this authorShelley PeacockPublished Online:4 Feb 2016https://doi.org/10.12968/bjcn.2016.21.2.76AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail View article References Akdis CA, Akdis M, Bieber T et al. (2006) Diagnosis and treatment of atopic dermatitis in children and adults: European Academy of Allergology and Clinical Immunology/American Academy of Allergy, Asthma and Immunology/PRACTALL Consensus Report. Allergy 61(8): 969–87 Crossref, Medline, Google ScholarErsser S, Maguire S, Nicol N, Penzer R, Peters J (2007) Best Practice in Emollient Therapy: A Statement for Healthcare Professionals. Dermatology UK Ltd, Aberdeen Google ScholarNational Eczema Society (2015a) What is eczema? www.eczema.org/what-is-eczema (accessed 26 January 2016) Google ScholarNational Eczema Society (2015b) Treatments. www.eczema.org/basic-treatment (accessed 26 January 2016) Google ScholarNational Institute for Health and Care Excellence (2007) NICE guidelines [CG57]. Atopic eczema in under 12s: diagnosis and management. www.nice.org.uk/guidance/cg57 (accessed 18 January 2016) Google ScholarNational Institute for Health and Care Excellence (2011) NICE guidelines [CG116]. Food allergy in under 19s: assessment and diagnosis. www.nice.org.uk/guidance/cg116 (accessed 18 January 2016) Google ScholarPeate I (2011) Eczema: causes, symptoms and treatment in the community. Br J Community Nurs 16(7): 324–31 Link, Google ScholarPenzer R, Ersser J (2010) Principles of Skin Care: A Guide for Nurses and Other Health Professionals. Wiley-Blackwell, Chichester Crossref, Google ScholarPenzer R (2012) Best practice in emollient therapy. A statement for healthcare professionals. 3rd edn. Dermatological Nursing 11(4): S1–19 Google ScholarScottish Intercollegiate Guidelines Network (2011) National clinical guideline 125. Management of atopic eczema in primary care. http://sign.ac.uk/pdf/sign125.pdf (accessed 26 January 2016) Google ScholarSehra S, Tuana FM, Holbreich M et al. (2008) Scratching the surface: towards understanding the pathogenesis of atopic dermatitis. Crit Rev Immunol 28(1): 5–43 Crossref, Google ScholarShamssain M (2007) rends in the prevalence and severity of asthma, rhinitis and atopic eczema in 6- to 7- and 13- to 14-yr-old children from the north-east of England. Pediatr Allergy Immunol 18(2): 149–53 Crossref, Medline, Google ScholarVoegeli D, Smith & Nephew Foundation (2007) Factors that exacerbate skin breakdown and ulceration. In: Skin Breakdown: The Silent Epidemic. Smith & Nephew Foundation, London, UK: 17–21 Google Scholar FiguresReferencesRelatedDetailsCited byHygiene and emollient interventions for maintaining skin integrity in older people in hospital and residential care settings23 January 2020 | Cochrane Database of Systematic Reviews, Vol. 2020, No. 1Atopic Eczema: Genetic Associations and Potential Links to Developmental Exposures30 March 2017 | International Journal of Toxicology, Vol. 36, No. 3Reviewing emollients13 October 2016 | Nurse Prescribing, Vol. 14, No. 10 2 February 2016Volume 21Issue 2ISSN (print): 1462-4753ISSN (online): 2052-2215 Metrics History Published online 4 February 2016 Published in print 2 February 2016 Information© MA Healthcare LimitedPDF download

IntroductionLimited evidence is available on real-world management of atopic dermatitis (AD) among Asian adults. This cross-sectional study aimed to assess current approaches in AD diagnosis and management in Asia.MethodsPractising dermatologists regularly treating patients with moderate-to-severe AD were recruited from eight Asia–Pacific territories, namely Mainland China, Hong Kong, India, Japan, Singapore, South Korea, Taiwan, and Thailand. A survey was administered to eligible dermatologists after screening and taking informed consent. Data from fully completed submissions were analysed using descriptive statistics. The study was reviewed by the institutional review board in each territory.ResultsData from 271 dermatologists were included for analysis. About one-third (31.7%) reported that they referred to the Hanifin and Rajka criteria during diagnosis. The majority of dermatologists used clinical impression when assessing AD severity and treatment response. Reduction of eczema and pruritus was the primary treatment objective when managing both acute (98.1%) and chronic (69.1%) AD. More than half of dermatologists preferred adding systemic anti-inflammatory medication for patients who did not respond to maximized topical treatment, while 43.6% would switch to another systemic medication for those failing to respond to maximized systemic treatment. Topical corticosteroids were frequently selected by dermatologists. For systemic therapies, oral corticosteroids were most frequently used, followed by cyclosporin and dupilumab. Narrow-band ultraviolet B was the most common phototherapy reported (84.9%). There was considerable variation in estimated average and maximum durations of therapies used to treat AD.ConclusionThis study has provided insights on the real-world management of moderate-to-severe AD in the Asia–Pacific region. The diverse approaches in diagnosis and treatment highlight the multifactorial nature of AD, reliance on clinical judgement, and importance of personalized care. To improve outcomes in patients with AD, it will be crucial to develop biomarkers for diagnosis, reduce subjectivity in assessment, as well as promote access to newer and effective therapies.Supplementary InformationThe online version contains supplementary material available at 10.1007/s13555-024-01246-5.

Risk of myocardial infarction, ischemic stroke, and cardiovascular death in patients with atopic dermatitis

Exploring the Potential Causes of the Emergence of Hospitalists: Chicken vs. Egg

Summary The study has been conducted in January-February 2003. And the second study in March-May 2007. The questionnaires were given to every 10th patient over 18 years old, who registered for the first time during the episode. Questionnaires were distributed among 500 patients, 343 questionnaires were returned to the study team (response rate 68,6 percent). Study participants were asked their opinion about the institution where their primary care physician should work. 50 percents of employers and 86,9 percents of housewives preferred that family physician’s office should be situated near their living place. 50 percents of unemployed respondents as well as 47 percents of employees wished that their family physicians, narrow specialists and laboratories should be working in one building. 72 percent of respondents who earn 1001-1500 Litas (Lt) per month for one family member thought that it is more comfortable when their doctors work in their neighbourhood. Respondents with monthly income 1501-2000 Lt and more per for one family member (61,1 percent and 45,7 percent accordingly) had different opinion: they preferred that all primary and secondary care physicians and laboratories were situated in one building. Only 14,6 percent of retired study participants have not heard about possibility to be treated in day-hospitals in outpatient clinics. Students and schoolchildren were those who were mostly not informed about this possibility (73,9 percent). But most of the students and schoolchildren were positive that in case they need hospital treatment, preference would be given to day-hospital clinics (74,3 percent). Majority of housewives (71,3 percent), and businessmen (55,2 percent) would also prefer day-hospital clinics. Choice of retired and unemployed respondents were distributed almost equally: 53,8 percent of retired persons and 33,3 percent of unemployed would choose day-hospital clinics; 46,2 percent of retired and 52,2 percent of unemployed would prefer treatment in hospital. No statistically significant dependence was found between income for one family member and preferred choice of treatment. Respondents who earn more than 2000 Lt for one family member noted that in case they need hospital treatment, they would certainly choose day-hospital clinics (100 percent). Two thirds of study participants (67,9 percent) had negative opinion concerning offered innovation – that family doctor replaced earlier primary care physicians team consisting of district therapeutist, paediatrician, gynaecologist and surgeon. Most of those who had negative opinion were retired persons (81,7 percent), businessman (72,4 percent), technical employees, workers (71 percent) and housewives (69,8 percent). 86,0 percent of respondents reported that first physician they usually contacted was their family doctor. Most of them were retired parsons, students and schoolchildren, workers/technical employees and housewives (92,5 percent, 91,3 percent, 91 percent and 89,3 percent accordingly). Businessman (34,5 percent) preferred to contact the physician that they knew personally, superlatives and managers (14,3 percent) mostly referred to private physicians. 53,9 percent of respondents positively evaluated functioning of health care institutions. 88,2 percent of respondents with income 1501-2000 Lt per month for one family member evaluated it well or very well, the same opinion had 74 percent of respondents earning income 1001-1500 Lt per month. 63,3 percent of respondents with average income up to 500 Lt per month work of health care institutions assessed as satisfactory. Respondents who earn more than 2000 Lt per month per family member assessed functioning of health care institutions as follows: 20 percent – very good, 31,4 percent – good, 37,1 percent – satisfactory and 11,4 percent – bad.

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Health care reform should be driven by the goals of better patient experience, improved population health, lower per capita costs, and improved provider satisfaction. Electronic consultation (eConsult) services have been adopted by several jurisdictions in the United States, Canada, and Europe to improve access to specialists by primary care providers (PCPs) and are being heralded as a key component for delivery of coordinated care. The primary intent of an eConsult service is to provide PCPs with efficient, timely, direct access to specialist expertise to help guide the management of their patients, reduce the need for unnecessary face-to-face specialty consultations, and improve the quality of the initial face-to-face consultation when needed, through the preconsultative communication.In addition to improving access to care, eConsult services have been praised by PCPs and specialists for their educational value, in particular their ability to enrich practice-based learning. Less recognized, but equally important from the educational perspective, include the abilities of eConsult programs to promote reflection by PCPs and specialists, improve collegiality and professionalism between primary and specialist care, inform continuing professional development activities and maintenance of certification, and enhance training programs' teaching of effective communication and care coordination.As eConsult services become increasingly available, the medical community must leverage the educational opportunities inherent in eConsult programs to further improve the delivery of coordinated specialty care. The educational role of eConsults should be considered as a priority outcome in their evaluation and must be highlighted and optimized in next iterations of eConsult systems design.