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Background: Guidelines discourage the use of systemic corticosteroids for atopic dermatitis (AD), but their use remains widespread., Objectives: To reach consensus among an international group of AD experts on the use of systemic corticosteroids for AD., Methods: A survey consisting of statements accompanied by visual analogue scales ranging from 'strongly disagree' to 'neutral' to 'strongly agree' was distributed to the International Eczema Council (IEC). Consensus was reached in agreement on a statement if < 30% of respondents marked to the left of 'neutral' towards 'strongly disagree'., Results: Sixty of 77 (78%) IEC members participated. Consensus was reached on 12 statements, including that systemic corticosteroids should generally be avoided but can be used rarely for severe AD under certain circumstances, including a lack of other treatment options, as a bridge to other systemic therapies or phototherapy, during acute flares in need of immediate relief, in anticipation of a major life event or in the most severe cases. If used, treatment should be limited to the short term. Most respondents agreed that systemic corticosteroids should never be used in children, but consensus was not reached on that statement. The conclusions of our expert group are limited by a dearth of high-quality published evidence. If more stringent consensus criteria were applied (e.g. requiring < 20% of respondents marking towards 'strongly disagree'), consensus would have been reached on fewer statements., Conclusions: Based on expert opinion from the IEC, routine use of systemic corticosteroids for AD is generally discouraged and should be reserved for special circumstances., (© 2017 The Authors. British Journal of Dermatology published by John Wiley & Sons Ltd on behalf of British Association of Dermatologists.)

Background: Atopic dermatitis (AD) and asthma often coexist. Both diseases can have a major impact on the lives of children with AD and their caregivers., Aim: To investigate the association of patient characteristics, comorbidities and impact of AD on children who have both asthma and AD., Methods: Children with AD (n = 140) were selected from a larger cohort of children with a reported use of asthma medication. The Children's Dermatology Life Quality Index (CDLQI) was used to assess Quality of Life (QoL), and the Self-Assessed Eczema Area and Severity Index (SA-EASI) was used to measure AD severity. Characteristics assessed included: age, sex, and the number and type of atopic comorbidities. Medication use for AD was defined using the total number of AD prescriptions, the number of different topical AD prescriptions and the highest potency topical corticosteroid (TCS) used. Determinants of AD severity and QoL were evaluated using Spearman rank tests., Results: The following factors were most strongly associated with a lower QoL: characteristics of AD lesions (Spearman R s = 0.61-0.69, P < 0.01), a higher SA-EASI score (R s = 0.54, P < 0.01) and a larger number of different topical AD prescriptions (R s = 0.38, P < 0.01). The following factors were correlated with more severe AD: age (R s = -0.36, P < 0.01), larger number of different TCS preparations used (R s = 0.27, P < 0.05) and larger number of TCS prescriptions (R s = 0.25, P < 0.05)., Conclusion: In children with asthma and AD, the number of TCS preparations used is associated with lower QoL and increased AD severity., (© 2017 British Association of Dermatologists.)

Background: Long-term data of ciclosporin A (CsA) treatment in daily practice in patients with severe atopic dermatitis (AD) are lacking., Objectives: To perform a detailed analysis of drug survival, which is the length of time a patient continues to take a drug, for CsA in a long-term daily practice cohort of patients with AD. The secondary objective was to identify determinants of drug survival., Methods: Data were extracted from a retrospective cohort of patients treated with CsA for AD. Drug survival was analysed using Kaplan-Meier survival curves. Determinants of drug survival were analysed using uni- and multivariate Cox regression analyses with backward selection., Results: In total, 356 adult patients were analysed (386 patient-years). The overall drug survival rates were 34%, 18%, 12% and 4% after 1, 2, 3 and 6 years, respectively. Reasons for discontinuation were controlled AD (26·4%), side-effects (22·2%), ineffectiveness (16·3%), side-effects plus ineffectiveness (6·2%) or other reasons (11·0%). Older age was associated with a decreased drug survival related to controlled AD [hazard ratio (HR) 0·91]. Older age was also associated with a decreased drug survival related to side-effects (HR 1·14). An intermediate-to-high starting dose (> 3·5-5·0 mg kg(-1) daily) was associated with an increased drug survival related to ineffectiveness (HR 0·63)., Conclusions: This is the first study on drug survival for CsA treatment in AD. Older age was associated with decreased drug survival related to controlled AD and side-effects. An intermediate-to-high starting dose was associated with an increased drug survival related to ineffectiveness., (© 2015 British Association of Dermatologists.)

Background: The Dermatology Department of the University Medical Centre Utrecht, the Netherlands, developed an e-health portal for patients with atopic dermatitis (AD), consisting of e-consultation, a patient-tailored website, monitoring and self-management training., Objectives: To determine the cost-effectiveness of individualized e-health compared with usual face-to-face care for children and adults with AD., Methods: A randomized controlled cost-effectiveness study from a societal perspective in adults and parents of children with moderate AD. Outcomes were quality of life, severity of AD, itching and direct and indirect costs. Data were collected at baseline and at 3 and 12 months after randomization. Linear mixed models were used to analyse clinical outcomes. After multiple imputation of missing data, costs and differences in costs were calculated over a period of 1 year., Results: In total, 199 patients were included. There were no significant differences in disease-specific quality of life, severity of AD and intensity of itching between both groups at the three time points. The difference in direct costs between the intervention and control groups was €24 [95% confidence interval (CI) -360 to 383], whereas this difference was -€618 (95% CI -2502 to 1143) for indirect costs. Overall, individual e-health was expected to save €594 (95% CI -2545 to 1227) per patient in the first year of treatment, mainly through a reduction in work absenteeism. Uncertainty analyses revealed that the probability of e-health reducing costs was estimated to be ≥ 73%., Conclusions: E-health during follow-up of patients with AD is, after initial diagnosis and treatment during face-to-face contact, just as effective as usual face-to-face care with regard to quality of life and severity of disease. However, when costs are considered, e-health is likely to result in substantial cost savings. Therefore, e-health is a valuable service for patients with AD., (© 2012 The Authors. BJD © 2012 British Association of Dermatologists.)

Background: Atopic dermatitis (AD) is a chronic inflammatory skin disease commonly treated with topical corticosteroids. The inflammatory nature of this disorder and the use of topical corticosteroids represent potential risk factors for bone loss., Objectives: The aim was to assess the prevalence of osteoporosis and osteopenia in adult patients with moderate to severe AD. In addition, the associations between topical/oral corticosteroid use and bone mineral density (BMD) and between disease activity and BMD were studied., Patients and Methods: We studied 125 adult patients with moderate to severe AD. Using dual-energy X-ray absorptiometry, BMD was measured at lumbar spine and hips. The cumulative dose of topical and oral corticosteroids was calculated from pharmacy prescription records. Lifestyle parameters were collected by a questionnaire. Biochemical parameters of bone metabolism and disease activity [serum concentration of thymus and activation-regulated chemokine (TARC) levels] were also measured., Results: Osteoporosis was documented in six patients (4.8%) and osteopenia in 41 patients (32.8%); 30.4% of the patients had a Z-score

Background: Severe atopic dermatitis (AD) is often treated successfully with oral immunosuppressive drugs such as cyclosporin (CsA) or oral corticosteroids. However, some patients develop adverse effects or are unresponsive to these first-choice oral immunosuppressive drugs., Objectives: To evaluate whether enteric-coated mycophenolate sodium (EC-MPS) is an effective treatment in patients with severe, recalcitrant AD., Methods: Ten patients with severe, recalcitrant AD were treated with EC-MPS 720 mg twice daily for 6 months. All patients had to discontinue other oral immunosuppressive drugs due to adverse effects (n = 8) or nonresponsiveness (n = 2). Disease activity was monitored using the Severity Scoring of Atopic Dermatitis (modified SCORAD) index and the Leicester Sign Score (LSS). Additionally, the level of serum thymus and activation-regulated cytokine (TARC) was measured. During treatment, safety laboratory examination was performed. Total serum immunoglobulin E (IgE) was followed during treatment. Use of topical corticosteroids was recorded before and during treatment., Results: Compared with baseline, the mean scores for disease activity significantly decreased during treatment with EC-MPS [modified SCORAD (P = 0.04), LSS severity (P = 0.01), LSS extent (P = 0.01)]. In addition, serum TARC levels and total serum IgE levels significantly decreased after treatment compared with before (P = 0.03; P = 0.05). Disease activity decreased after approximately 2 months of treatment and stabilized during the 6-month treatment period. No differences in the amount of topical corticosteroids used in the 6 months prior to treatment compared with the 6-month treatment period were found (P = 0.4). None of the patients discontinued use of EC-MPS and only mild adverse effects were seen., Conclusions: In this study EC-MPS at a dose of 720 mg twice daily for 6 months has proven to be an effective and well-tolerated treatment for patients with severe, recalcitrant AD.

Background: Topical corticosteroids are used extensively to treat inflammatory skin disorders including atopic dermatitis (AD). Several studies have described temporary reversible suppression of hypothalamic-pituitary-adrenal function. However, sound evidence of permanent disturbance of adrenal gland function is lacking., Objectives: To relate basal cortisol levels to prior use of topical corticosteroids and disease activity in patients with moderate to severe AD and to investigate the effect on basal serum cortisol levels of topical corticosteroid treatment during hospitalization., Methods: Two groups of patients with AD were evaluated: 25 inpatients with severe AD who required hospitalization (group 1) and 28 outpatients with moderate to severe AD (group 2). In group 1, morning basal serum cortisol levels were measured twice, at admission and at discharge; in group 2, morning basal serum cortisol levels were measured once. Use of topical corticosteroids in the 3 months prior to the cortisol measurement was recorded and disease activity was monitored using the Six Area, Six Sign Atopic Dermatitis (SASSAD) score and serum thymus and activation-regulated chemokine (TARC) levels., Results: On admission, basal cortisol levels in group 1 were significantly (P < 0.001) decreased in 80% of the patients. In group 2, the basal cortisol levels were normal in all but three patients. Comparing the two groups, group 1 on admission had a significantly lower cortisol level than that of group 2 (P < 0.001). Disease activity in group 1 on admission was significantly higher than that of group 2 (P < 0.001). There was no difference in use of topical corticosteroids in the 3 months before cortisol measurement. At discharge in group 1 there was a significant increase (P < 0.0001) of basal cortisol levels and a significant (P < 0.001) decrease in disease activity reflected by the decrease in serum TARC levels and SASSAD score., Conclusions: Disease activity, rather than the use of topical corticosteroids, is responsible for the low basal cortisol values in patients with severe AD.