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Background: Atopic dermatitis (AD) is a relapsing chronic inflammatory skin disease with a significant public health burden., Objectives: To conduct a survey in order to gain information on current problems on the care and treatment of AD patients from a wide range of care providers, as well as information on ways of improving AD guidelines., Materials & Methods: An online survey was conducted via professional associations, focussing on AD health care professionals with regards to current gaps in knowledge of AD management and experience based on the German guidelines (GL)., Results: In total, 542 respondents treated a median of 200 AD patients yearly. The most frequent problems in the management of AD concerned emollients (50%), largely due to patient costs and the inability to prescribe emollients/moisturizers. Barriers to prescribing biologics included cost. Respondents stated that the GL lacks information regarding patient education (27%) and use of basic emollients (27%). Consideration should be given to feasibility issues (32%) and the addition of care pathways (41%) to improve the GL., Conclusion: In this survey, we identified inadequate basic AD care mainly due to patient costs and lack of time for counselling as real-life challenges. These issues remain to be addressed in future guidelines.

Background: Atopic dermatitis (AD) is a common, chronic skin disorder often beginning in infancy. Skin barrier dysfunction early in life serves as a central event in the pathogenesis of AD. In infants at high risk of developing AD, preventative application of lipid-rich emollients may reduce the risk of developing AD. This study aims to measure the effectiveness of this intervention in a population not selected for risk via a pragmatic, randomized, physician-blinded trial in the primary care setting., Methods: Infant-parent dyads are recruited from a primary care practice participating through one of four practice-based research networks in Oregon, Colorado, Wisconsin, and North Carolina. Eligible dyads are randomized to the intervention (daily use of lipid-rich emollient) or the control (no emollient) group (n = 625 infants in each) and are followed for 24 months. The primary outcome is the cumulative incidence of physician-diagnosed AD and secondary outcomes include caregiver-reported measures of AD and development of other atopic diseases. Data collection occurs via chart review and surveys, with no study visits required. Data will be analyzed utilizing intention-to-treat principles., Discussion: AD is a common skin condition in infants that affects quality of life and is associated with the development of other atopic diseases. If a safe intervention, such as application of lipid-rich emollients, in the general population effectively decreases AD prevalence, this could alter the guidance given by providers regarding routine skin care of infants. Because of the pragmatic design, we anticipate that this trial will yield generalizable results., Trial Registration: ClinicalTrials.gov: NCT03409367. Registered on 11 February 2018.

Background: Currently, few studies investigated the economic burden of atopic dermatitis (AD) in adult patients and specifically the estimation of out-of-pocket costs. Patients with skin disorders primarily use comfort care to ease dryness, itch or pain, and the costs of comfort care are not subject to any reimbursement from mandatory or complementary insurance., Objective: The purpose of this study was to measure the medical and non-medical expenses paid by the patient., Methods: Eczema Cohort Longitudinal Adults was a non-interventional study that aimed to assess the burden of AD in terms of quality of life and financial consequences. A self-assessment questionnaire was distributed to adult patients who were cared in four French hospitals. Patients were asked to list the resources consumed for the treatment of AD during the last 12 months and to estimate the corresponding amount of money they had to pay out of their own pockets. The severity of AD was subjected to a stratification based on the PO-SCORAD score., Results: A total of 1024 patients answered the questionnaire: 31.9% with severe AD, 40.4% with moderate AD and 27.6% with mild AD. The mean annual out-of-pocket cost was €462.1 for severe AD and €247.4 for moderate AD. Emollients were the most commonly used product: 74.4% for an average out-of-pocket cost of €151.4. The out-of-pocket costs increased significantly with the severity: 27% of patients with severe AD declared having bought specially textured clothes, while 19% of patients with moderate AD reported the same. The corresponding mean out-of-pocket costs were €162 and €91, respectively., Conclusion: The amount of out-of-pocket costs for patients with AD for essential medical and non-medical expenses is relatively high, compared to the average out-of-pocket cost for French households. Integration of these essential resources into the list of reimbursed products and services appears necessary for a better coverage of AD., (© 2019 European Academy of Dermatology and Venereology.)

Objective: Eczema, a chronic dermatologic disease, has been recognized as an economic burden in publications all over the word but only minimally as such in Vietnam. The aim of this prospective study was to quantify the financial hardships and impairments suffered by eczema patients., Methods: This cross-sectional prevalence-based study involved 136 patients, whose conditions were classified into three severity levels on the basis of the medications that they were prescribed. Prescription therapy was administered for a month, after which there was patient-oriented assessment of effectiveness. The work productivity and activity impairment (WPAI) questionnaire was used to evaluate productivity loss, which was expressed in percentage form. Bootstrapping was conducted to determine continuous variables and demographybased differences in cost values among the patient groups., Results: For the month-long treatment, each eczema patient needed an average of US$68.1 (range: US$56.2- US$81.5) with the highest proportion being spent on cosmetic treatments. There is noticeable difference between groups among which patients' symptoms demonstrated in distinct levels. The estimates indicated that eczema resulted in 27.8% and 23.1% impairments in work and daily activities, respectively., Conclusions: The aggravation of disease symptoms can increase the direct costs borne by eczema patients. A decrease in productivity, which is one of the most serious consequences of the condition, should be paid adequate attention to minimize burdens to society.

Objectives: Eczema, which is synonymous with atopic eczema, is classified as a complex, chronic, and relapsing inflammatory skin condition, affecting both adults and children. However, there has not been any research into health-care expenditure to evaluate the medical cost of eczema from patients' perspective in Vietnam. This retrospective study aimed to fill in the gap concerning the medical cost of eczema treatment from patients' perspective., Methods: Data from Ho Chi Minh City Hospital of Dermato Venereology's electronic medical database on demographics and drug therapy from June 2016 to May 2017 were collected. The patients who met the study's criteria were included in the study and were then categorized as mild, moderate, and severe according to received treatment level. Bootstrapping methods were used to evaluate average and emphasized the difference of cost burden adjusted by factors., Results: A total of 6,212 patients (52.1% women and 85% urban residents) participated in the study; they were divided into three groups according to treatment stage: mild (n = 3,159, 50.9%), moderate (n = 599, 9.6%), and severe (n = 2,454, 39.5%). The evaluated total cost for the three groups was 5,255.82, 1,064.03, and 5,8154.60 US dollars, respectively; the average expenditure per patient per year was around $12.11 ($11.63-12.59)., Conclusions: The results suggested that the estimated direct medical cost of eczema treatment was much lower than that in the Western countries, mostly because of insurance coverage. The findings provide useful insights into health economic evaluations and treatment costs of eczema in Vietnam.

Background: The Clinical Practice Research Datalink (CPRD) was used to evaluate the overall costs to the National Health Service, including healthcare utilisation, of prescribing emollients in UK primary care for dry skin and atopic eczema (DS&E)., Methods: Primary care patients in the UK were identified using the CPRD and their records were interrogated for the 2 years following first diagnosis of DS&E. Data from patients with (n = 45,218) and without emollient prescriptions (n = 9780) were evaluated. Multivariate regression models were used to compare healthcare utilisation and cost in the two matched groups (age, sex, diagnosis). Two sub-analyses of the Emollient group were performed between matched groups receiving (1) a colloidal oatmeal emollient (Aveeno-First) versus non-colloidal oatmeal emollients (Aveeno-Never) and (2) Aveeno prescribed first-line (Aveeno-First) versus prescribed Aveeno later (Aveeno-Subsequently). Logistic regression models calculated the odds of prescription with either potent / very potent topical corticosteroids (TCS) or skin-related antimicrobials., Results: Costs per patient were £125.80 in Emollient (n = 7846) versus £128.13 in Non-Emollient (n = 7846) matched groups (p = 0.08). The Emollient group had fewer visits/patient (2.44 vs. 2.66; p < 0.0001) and lower mean per-visit costs (£104.15 vs. £113.25; p < 0.0001), compared with the Non-Emollient group. Non-Emollient patients had 18% greater odds of being prescribed TCS and 13% greater odds of being prescribed an antimicrobial than Emollient patients. In the Aveeno-First (n = 1943) versus Aveeno-Never (n = 1943) sub-analysis, costs per patient were lower in the Aveeno-First compared with the Aveeno-Never groups (£133.46 vs. £141.11; p = 0.0069). The Aveeno-Never group had ≥21% greater odds of being prescribed TCS or antimicrobial than the Aveeno-First group. In the Aveeno-First (n = 1357) versus Aveeno-Subsequently (n = 1357) sub-analysis, total costs were lower in the Aveeno-First group (£140.35 vs. £206.43; p < 0.001). Patients in the Aveeno-Subsequently group had 91% greater odds of being prescribed TCS and 75% greater odds of being prescribed an antimicrobial than the Aveeno-First group., Conclusions: Acknowledging limitations from unknown disease severity in the CRPD, the prescription of emollients to treat DS&E was associated with fewer primary care visits, reduced healthcare utilisation and reduced cost. Prescribing emollients, especially those containing colloidal oatmeal, was associated with fewer TCS and antimicrobial prescriptions., Trial Registration: The study is registered at http://isrctn.com/ISRCTN91126037 .

Background: Childhood eczema is very common. Treatment often includes emollient bath additives, despite there being little evidence of their effectiveness., Objectives: To determine the clinical effectiveness and cost-effectiveness of emollient bath additives in the management of childhood eczema., Design: Pragmatic, randomised, open-label, multicentre superiority trial with two parallel groups., Setting: Ninety-six general practices in Wales, the west of England and southern England. Invitation by personal letter or opportunistically., Participants: Children aged between 12 months and 12 years fulfilling the UK Diagnostic Criteria for Atopic Eczema. Children with inactive or very mild eczema (a score of ≤ 5 on the Nottingham Eczema Severity Scale) were excluded, as were children who bathed less than once per week or whose parents/carers were not prepared to accept randomisation., Interventions: The intervention group were prescribed bath additives by their usual clinical team and were asked to use them regularly for 12 months. The control group were asked to use no bath additives for 12 months. Both groups continued standard eczema management, including regular leave-on emollients and topical corticosteroids (TCSs) when required., Main Outcome Measures: The primary outcome was eczema control measured by Patient Oriented Eczema Measure [POEM, 0 (clear) to 28 (severe)] weekly for 16 weeks. The secondary outcomes were eczema severity over 1 year (4-weekly POEM), number of eczema exacerbations, disease-specific quality of life (QoL) (Dermatitis Family Impact Questionnaire), generic QoL (Child Health Utility-9 Dimensions) and type and quantity of topical steroid/calcineurin inhibitors prescribed. Children were randomised (1 : 1) using online software to either bath additives plus standard eczema care or standard eczema care alone, stratified by recruiting centre, and there was open-label blinding., Results: From December 2014 to May 2016, 482 children were randomised: 51% were female, 84% were white and the mean age was 5 years ( n  = 264 in the intervention group, n  = 218 in the control group). Reported adherence to randomised treatment allocation was > 92% in both groups, with 76.7% of participants completing at least 12 (80%) of the first 16 weekly questionnaires for the primary outcome. Baseline POEM score was 9.5 [standard deviation (SD) 5.7] in the bath additives group and 10.1 (SD 5.8) in the no bath additives group. Average POEM score over the first 16 weeks was 7.5 (SD 6.0) in the bath additives group and 8.4 (SD 6.0) in the no bath additives group, with no statistically significant difference between the groups. After controlling for baseline severity and confounders (ethnicity, TCS use, soap substitute use) and allowing for clustering of participants within centres and responses within participants over time, POEM scores in the no bath additive group were 0.41 points higher than in the bath additive group (95% confidence interval -0.27 to 1.10), which is well below the published minimal clinically important difference of 3 points. There was no difference between groups in secondary outcomes or in adverse effects such as redness, stinging or slipping., Limitations: Simple randomisation resulted in an imbalance in baseline group size, although baseline characteristics were well balanced between groups., Conclusion: This trial found no evidence of clinical benefit of including emollient bath additives in the standard management of childhood eczema., Future Work: Further research is required on optimal regimens of leave-on emollients and the use of emollients as soap substitutes., Trial Registration: Current Controlled Trials ISRCTN84102309., Funding: This project was funded by the NIHR Health Technology Assessment Programme and will be published in full in Health Technology Assessment ; Vol. 22, No. 57. See the NIHR Journals Library website for further project information., Competing Interests: Matthew J Ridd is a member of the National Institute for Health Research (NIHR) Health Technology Assessment (HTA) General Board. Nick A Francis was a member of the HTA Antimicrobial Resistance Themed Call Board during the study. Amanda Roberts is a member of the HTA General Board. As patient and public involvement co-applicant, Amanda Roberts also received an attendance allowance and travel expenses from the University of Southampton in order to attend meetings. Emma Thomas-Jones reports grants from the NIHR HTA programme during the conduct of the study. Hywel C Williams is Director of the NIHR HTA programme. Paul Little is a member of the NIHR Journals Library Board.

Background: Eczema and asthma are chronic diseases with onset usually before the age of 5 years. More than 50% of individuals with eczema will develop asthma and/or other allergic diseases. Several loss-of-function mutations in filaggrin (FLG) have been identified in patients with eczema. However, the association of FLG with healthcare use is unknown., Objectives: To determine whether FLG mutations are associated with increased prescribing for eczema and asthma and whether increased prescribing is associated with increased healthcare costs., Methods: A secondary analysis of BREATHE, a cross-sectional study of gene-environment associations with asthma severity, was undertaken. BREATHE data was collected for 1100 participants with asthma, in Tayside and Fife, Scotland during the period 2003-2005. Through collaboration with the Health Informatics Centre in Dundee, BREATHE was linked to accident and emergency, community prescribing and Scottish morbidity records. The data linkage allowed longitudinal exploration of associations between genetic variation and prescribing., Results: An association was found between FLG mutations and increased prescribing for mild and moderate eczema, asthma-reliever medicine and asthma exacerbations. A strong association was found between FLG mutations and prescribing of emollients [incidence rate ratio (IRR) 2·19, 95% confidence interval (CI) 1·36-3·52], treatment for severe eczema (IRR 2·18, 95% CI 1·22-3·91) and a combination of a long-acting β 2 -agonist and corticosteroids (IRR 3·29, 95% CI 1·68-6·43)., Conclusions: The presence of FLG mutations in this cohort is associated with increased prescribing for eczema and asthma. Randomized controlled trials are required to determine if these individuals could benefit from management strategies to reduce morbidity and treatment costs., (© 2018 The Authors. British Journal of Dermatology published by John Wiley & Sons Ltd on behalf of British Association of Dermatologists.)

Background: Moderate-to-severe atopic dermatitis can be difficult and costly to treat. The long-term health and economic outcomes of a new therapy, dupilumab, have yet to be evaluated. We aimed to identify the cost-effectiveness of dupilumab compared to usual care in moderate-to-severe atopic dermatitis., Methods: We compared dupilumab to usual care with emollients for adults with moderate-to-severe atopic dermatitis inadequately controlled with topical therapy, or for whom topical therapies were medically inadvisable. Subpopulations of moderate and severe patients were examined separately. We used a lifetime Markov model from a US payer perspective with health states categorized by the percent decrease in Eczema Area and Severity Index (EASI) score after a patient began an intervention: at least a 50% decrease (EASI 50), 75% decrease (EASI 75), 90% decrease (EASI 90), or no response., Results: The expected lifetime cost for patients treated with dupilumab was $509,600, including $267,800 in dupilumab drug costs and $241,800 in other healthcare costs. Average lifetime cost for usual care was $271,500. Dupilumab provided an additional 1.91 quality-adjusted life years (QALYs) over the remaining lifetime of a patient, leading to an incremental cost-effectiveness ratio (ICER) of $124,500. The ICER was lower for patients with severe atopic dermatitis ($95,800) than those with moderate atopic dermatitis ($160,000). Key drivers of the model were utility values for quality-of-life for non-responders, and the price of dupilumab., Conclusions: This study was limited by data for health outcomes and costs over long time periods, particularly stratified by severity. We estimated that dupilumab improved health outcomes compared to usual care but with additional costs, with an ICER below commonly cited thresholds for cost-effectiveness. Dupilumab was projected to be more cost-effective in patients with severe atopic dermatitis, but even in patients with moderate atopic dermatitis, the ICER remained below the upper range of commonly cited thresholds. J Drugs Dermatol. 2018;17(7):750-756.

Objective: To identify and compare emollient formularies across all clinical commissioning groups (CCGs) and local health boards (LHBs) in England and Wales., Design: Formularies were retrieved via CCG/LHB websites or Google search (October 2016-February 2017). Data on structure and content were extracted, and descriptive analyses were undertaken., Setting: 209 English CCGs and 7 Welsh LHBs., Main Outcome Measures: Number and structure of formularies; number, type and name of emollients and bath additive recommendedandnot recommended; and any rationale given., Results: 102formularies were identified, which named 109 emollients and 24 bath additives. Most were structured in an 'order of preference' (63%) and/or formulation (51%) format. Creams and ointments were the most commonly recommended types of emollients, and three ointments were the most commonly recommended specific emollients (71%-79% of formularies). However, there was poor consensus over which emollient should be used first line and 4 out of 10 of the most recommended lotions and creams contained antimicrobials or urea. Patient preference (60%) and/or cost (58%) were the most common reasons given for the recommendations. Of the 82% of formularies that recommend the use of bath additives, 75% did not give any reasons for their recommendation., Conclusions: Emollient formularies in England and Wales vary widely in their structure, recommendations and rationale. The reasons for such inconsistencies are unclear, risk confusion and make for inequitable regional variation. There is poor justification for multiple different, conflicting formularies., Competing Interests: Competing interests: MJR reports grants from National Institute for Health Research (NIHR) Post Doctoral Fellowship (PDF-2014-07-013) and NIHR HTA (11/153/01 and 15/130/07). JPC and GB report grants from The Academy of Medical Sciences INSPIRE scheme., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Importance: Because moisturizer use is critical for the prevention and treatment of numerous dermatological conditions, patients frequently request product recommendations from dermatologists., Objective: To determine the product performance characteristics and ingredients of best-selling moisturizers., Design and Setting: This cohort study involved publicly available data of the top 100 best-selling whole-body moisturizing products at 3 major online retailers (Amazon, Target, and Walmart). Products marketed for use on a specific body part (eg, face, hands, eyelids) were excluded., Main Outcomes and Measures: Pairwise comparisons of median price per ounce on the basis of marketing claims (eg, dermatologist recommended, fragrance free, hypoallergenic) and presence of ingredients represented in the North American Contact Dermatitis Group (NACDG) series were conducted using Wilcoxon rank sum tests. The effect of vehicle type (eg, ointment, lotion, cream, butter) was assessed using the Kruskal-Wallis test. Cross-reactors and botanicals for fragrances were derived from the American Contact Dermatitis Society's Contact Allergen Management Program database., Results: A total of 174 unique best-selling moisturizer products were identified, constituting 109 713 reviews as of August 2016. The median price per ounce was $0.59 (range, $0.10-$9.51 per ounce) with a wide range (9400%). The most popular vehicles were lotions (102 [59%]), followed by creams (22 [13%]), oils (21 [12%]), butters (14 [8%]), and ointments (3 [2%]). Only 12% (n = 21) of best-selling moisturizer products were free of NACDG allergens. The 3 most common allergens were fragrance mix (n = 87), paraben mix (n = 75), and tocopherol (n = 74). Products with the claim "dermatologist recommended" had higher median price per ounce ($0.79; interquartile range [IQR], $0.56-$1.27) than products without the claim ($0.59; IQR, $0.34-$0.92). Products with the claim "phthalate free" had higher median price per ounce ($1.38; IQR, $0.86-$1.63) than products without the claim ($0.59; IQR, $0.35-$0.91). Lotions (median, $0.49; IQR, $0.31-0.68) were statistically less expensive per ounce than butters (median, $1.20; IQR, $0.76-$1.63), creams (median, $0.80; IQR, $0.69-$1.25) and oils (median, $1.30; IQR, $0.64-$2.43). For products with a claim of "fragrance free," 18 (45%) had at least 1 fragrance cross-reactor or botanical ingredient. Products without any ingredients in the NACDG (median, $0.83; IQR, $0.47-$1.69) were not statistically more expensive per ounce than products with 1 or more allergens (median, $0.60; IQR, $0.35-$1.06)., Conclusions and Relevance: Best-selling moisturizers vary widely by price and product characteristics. Given the lack of readily available comparison data on moisturizer efficacy, dermatologists should balance consumer preference, price, and allergenicity in their recommendations.

Background: Atopic eczema (AE) is a common skin problem that impairs quality of life and is associated with the development of other atopic diseases including asthma, food allergy and allergic rhinitis. AE treatment is a significant cost burden for health care providers. The purpose of the trial is to investigate whether daily application of emollients for the first year of life can prevent AE developing in high-risk infants (first-degree relative with asthma, AE or allergic rhinitis)., Methods: This is a protocol for a pragmatic, two-arm, randomised controlled, multicentre trial. Up to 1400 term infants at high risk of developing AE will be recruited through the community, primary and secondary care in England. Participating families will be randomised in a 1:1 ratio to receive general infant skin-care advice, or general skin-care advice plus emollients with advice to apply daily to the infant for the first year of life. Families will not be blinded to treatment allocation. The primary outcome will be a blinded assessment of AE at 24 months of age using the UK Working Party Diagnostic Criteria for Atopic Eczema. Secondary outcomes are other definitions of AE, time to AE onset, severity of AE (EASI and POEM), presence of other allergic diseases including food allergy, asthma and hay fever, allergic sensitisation, quality of life, cost-effectiveness and safety of the emollients. Subgroup analyses are planned for the primary outcome according to filaggrin genotype and the number of first-degree relatives with AE and other atopic diseases. Families will be followed up by online and postal questionnaire at 3, 6, 12 and 18 months with a face-to-face visit at 24 months. Long-term follow-up until 60 months will be via annual questionnaires., Discussion: This trial will demonstrate whether skin-barrier enhancement through daily emollient for the first year of life can prevent AE from developing in high-risk infants. If effective, this simple and cheap intervention has the potential to result in significant cost savings for health care providers throughout the world by preventing AE and possibly other associated allergic diseases., Trial Registration: ISRCTN registry; ID: ISRCTN21528841 . Registered on 25 July 2014.

Importance: Emerging evidence suggests that the use of moisturizers on newborns and infants (ie, from birth to 6 months of age) is potentially helpful in preventing the development of atopic dermatitis., Objective: To investigate the cost-effectiveness of using a daily moisturizer as prevention against atopic dermatitis among high-risk newborns., Design, Setting, and Participants: In a cost-effectiveness analysis, the average cost of total-body moisturization using 7 common moisturizers from birth to 6 months of age was determined for male and female infants. We assumed the same unit of weight per moisturizer used for a given body surface area. Based on previously reported data (relative risk reduction of 50%), the incremental gain in quality-adjusted life-years (QALYs) was determined using a 6-month time window. The cost-effectiveness of each moisturizer was determined by assuming equal efficacy. A sensitivity analysis was conducted by varying the relative risk from 0.28 to 0.90., Interventions: Use of prophylactic moisturizing compounds., Main Outcomes and Measures: The primary outcomes were the incremental cost-effectiveness values ($/QALY) for each moisturizer in preventing atopic dermatitis during a 6-month time window., Results: The calculated amount of daily all-body moisturizer needed at birth was 3.6 g (0.12 oz) per application, which increased to 6.6 g (0.22 oz) at 6 months of age. Of the 7 products evaluated, the average price was $1.07/oz (range, $0.13/oz-$2.96/oz). For a 6-month time window, the average incremental QALY benefit was 0.021. The sensitivity analysis showed that the incremental gain of QALY ranged from 0.0041 to 0.030. Petrolatum was the most cost-effective ($353/QALY [95% CI, $244-$1769/QALY) moisturizer in the cohort. Even assuming the lowest incremental QALYs for the most expensive moisturizer, the intervention was still less than $45 000/QALY., Conclusions and Relevance: Overall, atopic dermatitis represents a major health expenditure and has been associated with multiple comorbidities. Daily moisturization may represent a cost-effective, preventative strategy to reduce the burden of atopic dermatitis.

Atopic dermatitis is a chronic skin disorder with high prevalence, especially in the Nordic countries. Effective maintenance therapy during symptom-free episodes may prolong the time to eczema relapse according to a previously published clinical trial. The present study evaluates the cost-effectiveness of a barrier-strengthening moisturizer containing 5% urea, compared with a moisturizer with no active ingredients during eczema-free periods. A health economic microsimulation model, based on efficacy data from the randomized clinical trial, analysed the cost-effectiveness of the barrier-strengthening treatment in Finland, Norway and Sweden. The barrier-strengthening moisturizer was cost-saving compared with the moisturizer with no active ingredients in all 3 countries. The result was confirmed in all but one sensitivity analysis. In conclusion, the barrier-strengthening moisturizer is cost-effective as maintenance therapy for patients with atopic dermatitis compared with a moisturizer with no active ingredients.

Background: Eczema is common in children and in the UK most cases are managed in primary care. The foundation of all treatment is the regular use of leave-on emollients to preserve and restore moisture to the skin. This not only improves comfort but may also reduce the need for rescue treatment for 'flares', such as topical corticosteroids. However, clinicians can prescribe many different types of emollient and there is a paucity of evidence to guide this choice. One reason for this may be the challenges of conducting a clinical trial: are parents or carers of young children willing to be randomly allocated an emollient and followed up for a meaningful amount of time?, Design: This is a single-centre feasibility study of a pragmatic, four-arm, single-masked, randomized trial. Children with eczema who are eligible (from 1 month to less than 5 years of age, not known to be sensitive or allergic to any of study emollients or their constituents) are recruited via their general practices. Participants are allocated Aveeno® lotion, Diprobase® cream, Doublebase® gel or Hydromol® ointment via a web-based system, using a simple randomization process in a 1:1:1:1 fashion. Researchers are masked to the study emollient. Participants are assessed at baseline and followed up for 3 months. Data are collected by daily diaries, monthly researcher visits and review of electronic medical records. Because this is a feasibility study, a formal sample size calculation for the estimation of treatment effectiveness has not be made but we aim to recruit 160 participants., Discussion: Recruitment is on-going. At the end of the study, as well as being able to answer the question, 'Is it is possible to recruit and retain children with eczema from primary care into a four-arm randomized trial of emollients?', we will also have collected important data on the acceptability and effectiveness of four commonly used emollients., Trial Registration: Current Controlled Trials ISRCTN21828118 and Clinical Trials Register EudraCT2013-003001-26.

Background: Atopic dermatitis (AD) is a highly prevalent, chronic relapsing condition in childhood with significant financial burden and impact on the quality of life of patients and caregivers. Proactive maintenance treatment with moisturizing agents is the mainstay AD therapy., Objectives: The aim of this study was to assess the cost-effectiveness of a non-steroidal barrier cream (Atopiclair), compared to regular emollient in pediatric patients with mild-to-moderate AD., Methods: A Markov decision model was developed to evaluate the cost-effectiveness of Atopiclair versus regular emollient in 12 Asia-Pacific countries, grouped by income categories based on gross domestic product (GDP) per capita. Data was obtained from structured literature review, expert opinion, fee schedules, and findings from a 2012 survey of 12 Asia-Pacific countries. Analysis was performed a societal perspective., Results: In the base case analysis, Atopiclair was cost-effective against regular emollient, with USD786, USD499, and USD289 in cost savings per year for high, middle, and low-income countries, respectively. Sensitivity analyses showed that Atopiclair remained cost-effective versus regular emollient., Conclusions: Modelling analysis showed that Atopiclair is a cost-effective treatment compared to regular emollient for mild-to-moderate pediatric AD in the countries included in the study.

Atopic dermatitis (AD) affects both the epidermal barrier and the immune system and, as such, therapy needs to address both. Skin cleansing supported by emollients and moisturizers is the primary topical therapy when treating patients with AD. However, it should be remembered that the direct use of emollients on inflamed skin is poorly tolerated and that the flares need to be treated effectively, usually by topical corticosteroids (TCS) and/or topical calcineurin inhibitors (TCI). This contribution outlines a number of strategies for effectively managing AD, from reactive therapy using TCS and TCI to proactive therapy. Proactive therapy is an alternative, evidence-based, immunologically founded treatment approach, based on the fact that normal-looking, nonlesional skin of patients with AD is not normal. The advantage of the proactive approach is that the patients are in control of their disease and are actively involved in its management. The avoidance of external irritants is recommended wherever possible., (© 2014 The Authors BJD © 2014 British Association of Dermatologists.)

Background: Parents and carers of children with eczema often underuse emollient therapy, essential to repairing and protecting the defective skin barrier in atopic eczema. Educational interventions delivered by specialist dermatology nurses in hospital settings have been shown to improve emollient use and reduce symptoms of atopic eczema, but benefits of community-based interventions are uncertain. Support and information about appropriate care may often be inadequate for patients and carers in the community., Methods: A multifaceted educational support programme was evaluated as a method of increasing emollient use and reducing atopic eczema in children. Support provided for parents and carers included an educational DVD, online daily diary and telephone helpline. The before and after study included 136 British children and their parents, providing baseline and 12 week follow-up data while receiving the programme. Measures included emollient use, POEM and PEST scores, and cost of care., Results: Average emollient use increased by 87.6 g (95% CI: 81.9 to 119.5 g, p = 0.001) from baseline with the change being immediate and persistent. The POEM score reduced on average by 5.38 (95% CI: 4.36 to 6.41, p = 0.001), a 47% reduction from baseline. Similarly the PEST score reduced on average by 0.61 (95% CI: 0.47 to 0.75, p = 0.001), a 48% reduction from baseline. Sleep disturbance was reduced by 1.27 nights per week (95% CI: 0.85 to 1.68, p = 0.001) and parental feeling of control improved by 1.32 points (95% CI: 1.16 to 1.48, p = 0.001). From the NHS perspective, the programme was cost neutral overall within the study period., Conclusion: A community-based multifaceted educational support programme greatly increased emollient use, reducing symptoms of atopic eczema and general practitioner contacts, without increasing cost. Significant benefits may accrue to the families and carers of children with atopic eczema due to improved sleep patterns and greater feeling of control. PEST, a new simple measure of acute and remitting atopic eczema severity designed to help parents and children to monitor and manage eczema, merits further evaluation.

An estimated 2% of the UK population has psoriasis. For many patients this affects the scalp. Particular challenges in managing scalp psoriasis include choosing an appropriate treatment option, difficulties of applying topical treatments and deciding how to treat severe disease. Moreover, there is a lack of good-quality evidence on which to base treatment decisions. Here, we offer some practical advice, taking into account the available evidence.

Background: Atopic dermatitis (AD) is a prevalent skin disorder with significant cost of treatment. Several prescription device moisturizers have been approved by the FDA to treat AD but are significantly more expensive than well-crafted over-the-counter (OTC) moisturizers. No studies have been performed to compare both the clinical efficacy and cost-efficacy of these prescription devices to OTC moisturizers., Purpose: The purpose of this study is to compare the clinical efficacy and cost-efficacy of a glycyrrhetinic acid-containing barrier repair cream (BRC-Gly, Atopiclair®), a ceramide-dominant barrier repair cream (BRC-Cer, EpiCeram®) and an OTC petroleum-based skin protectant moisturizer (OTC-Pet, Aquaphor Healing Ointment®) as monotherapy for mild-to-moderate AD in children., Methods: Thirty-nine patients, age 2-17 years, with mild-to-moderate AD were randomized 1:1:1 to receive one of three treatments-BRC-Gly, BRC-Cer or OTC-Pet-with instructions to apply the treatment three times daily for three weeks. Disease severity and improvement was assessed at baseline and on days 7 and 21., Results: No statistically significant difference for any efficacy assessment was found between the three groups at each time point. The OTC-Pet was found to be at least 47 times more cost-effective than BRC-Gly or BRC-Cer., Limitations: The relatively small sample size of 39 subjects was not sufficient to establish OTC-Pet as superior treatment in AD., Conclusions: OTC-Pet is as effective in treating mild-to-moderate AD as both BRC-Gly and BRC-Cer and is at least 47 times more cost-effective., Name of Registry: II-AF-ATD-Aquaphor, Comparing the Efficacy and Cost-Effectiveness of Aquaphor to Atopiclair and EpiCeram in Children with Mild to Moderate Atopic Dermatitis. REGISTRATION IDENTIFIER: NCT01093469.

Dry skin conditions are often not considered important by health professionals, and as a consequence treatments are frequently under-prescribed. As a result of this, problems with untreated dry skin can lead to a variety of issues. Conditions such as pruritus and ichthyosis vulgaris can be distressing, while ezcema and psoriasis can lead to more serious consequences such as fissures and infections and can result in a reduced quality of life and social isolation. However, with appropriate treatments such as emollient therapy, the incidences of these conditions occurring can be reduced. Despite a wide range of choice available on the market, choosing an effective emollient which will help aid concordance is often difficult. In order to achieve this, several factors need to be considered in conjunction with the product selection. This article discusses the various factors that nurses need to consider when advising patients on which emollient to use as part of their skin care regimen, in order to improve concordance and patient outcomes.

Background: Podoconiosis is a non-filarial elephantiasis caused by long-term barefoot exposure to volcanic soils in endemic areas. Irritant silicate particles penetrate the skin, causing a progressive, debilitating lymphoedema of the lower leg, often starting in the second decade of life. A simple patient-led treatment approach appropriate for resource poor settings has been developed, comprising (1) education on aetiology and prevention of podoconiosis, (2) foot hygiene (daily washing with soap, water and an antiseptic), (3) the regular use of emollient, (4) elevation of the limb at night, and (5) emphasis on the consistent use of shoes and socks., Methodology/principal Findings: We did a 12-month, non-comparative, longitudinal evaluation of 33 patients newly presenting to one clinic site of a non-government organization (the Mossy Foot Treatment & Prevention Association, MFTPA) in southern Ethiopia. Outcome measures used for the monitoring of disease progress were (1) the clinical staging system for podoconiosis, and (2) the Amharic Dermatology Life Quality Index (DLQI), both of which have been recently validated for use in this setting. Digital photographs were also taken at each visit. Twenty-seven patients completed follow up. Characteristics of patients completing follow-up were not significantly different to those not. Mean clinical stage and lower leg circumference decreased significantly (mean difference -0.67 (95% CI -0.38 to -0.96) and -2.00 (95% CI -1.26 to -2.74), respectively, p<0.001 for both changes). Mean DLQI diminished from 21 (out of a maximum of 30) to 6 (p<0.001). There was a non-significant change in proportion of patients with mossy lesions (p = 0.375)., Conclusions/significance: This simple, resource-appropriate regimen has a considerable impact both on clinical progression and self-reported quality of life of affected individuals. The regimen appears ideal for scaling up to other endemic regions in Ethiopia and internationally. We recommend that further research in the area include analysis of cost-effectiveness of the regimen.

Background: Atopic dermatitis (AD) affects health and quality of life and it has great impact on both health-care costs and costs to the society., Objectives: The objective of this study was to develop a model to analyse the cost-effectiveness of a barrier-strengthening moisturizing cream as maintenance therapy compared with no treatment after initial treatment with betamethasone valerate in adult patients with AD in Sweden. A further aim was to apply a similar health-economic analysis for Denmark, Norway and Finland., Methods: A Markov simulation model was developed including data from three sources: (i) efficacy data from a randomized controlled trial including patients with moderate AD treated with either a moisturizing cream or no treatment, (ii) resource utilization and quality of life data, and (iii) unit prices from official price lists. A societal perspective was used and the analysis was performed according to treatment practice in Sweden. The model simulation was also applied for Denmark, Norway and Finland with inclusion of country-specific unit costs. Sensitivity analyses were performed to test the robustness of the results., Results: The results from the present analyses of treatment for patients with moderate AD indicate that maintenance treatment with a moisturizing cream during eczema-free periods could be cost-effective in a societal perspective. Similar results were obtained for Sweden, Denmark, Norway and Finland., Conclusions: According to the analysis, treatment with a moisturizing cream was found to be a cost-effective option compared with no treatment in eczema-free periods in adult patients with AD in the four Nordic countries.

Objective: To evaluate the cost-effectiveness of topical emollients, sunflower seed oil (SSO) and synthetic Aquaphor, versus no treatment, in preventing mortality among hospitalized preterm infants (< 33 weeks gestation) at a tertiary hospital in Bangladesh., Methods: Evidence from a randomized controlled efficacy trial was evaluated using standard Monte Carlo simulation. Programme costs were obtained from a retrospective review of activities. Patient costs were collected from patient records. Health outcomes were calculated as deaths averted and discounted years of life lost (YLLs) averted. Results were deemed cost-effective if they fell below a ceiling ratio based on the per capita gross national income of Bangladesh (United States dollars, US$ 470)., Findings: Aquaphor and SSO were both highly cost-effective relative to control, reducing neonatal mortality by 26% and 32%, respectively. SSO cost US$ 61 per death averted and US$ 2.15 per YLL averted (I$ 6.39, international dollars, per YLL averted). Aquaphor cost US$ 162 per death averted and US$ 5.74 per YLL averted (I$ 17.09 per YLL averted). Results were robust to sensitivity analysis. Aquaphor was cost-effective relative to SSO with 77% certainty: it cost an incremental US$ 26 more per patient treated, but averted 1.25 YLLs (US$ 20.74 per YLL averted)., Conclusion: Topical therapy with SSO or Aquaphor was highly cost-effective in reducing deaths from infection among the preterm neonates studied. The choice of emollient should be made taking into account budgetary limitations and ease of supply. Further research is warranted on additional locally available emollients, use of emollients in community-based settings and generalizability to other geographic regions.

Emollient preparations play a central role in the treatment of people with dry skin associated with conditions such as atopic eczema.1,2 As well as being advised to apply emollient creams or ointments directly to the skin, people with atopic eczema are commonly prescribed bath emollients.3 Each year, the NHS spends over pound16million on bath emollients (at an average cost of pound6.29 per item).4 This represents 38% of the total cost of treatments prescribed for preschool children with eczema, matching the proportion spent on emollients for application directly to the skin.5 What clinical contribution do bath emollients make in the treatment of people with atopic eczema?

Foams offer an innovative and more convenient means of topical drug delivery. The successful introduction of hydroalcoholic foams paved the way for the development of a new generation of foam products that provide skin barrier build-up and hydration. Such foams, designated as emollient foams consist of oil-in-water or water-in-oil emulsions with necessary excipients, such as non-ionic surfactants, gelling agents and foam adjuvants. Emollient foams can carry a broad variety of topical drugs, including water-soluble, oil-soluble and suspended active agents. This paper reviews emollient foam compositions and their physicochemical properties. It further accounts for the usability and functional advantages of emollient foam as a vehicle of topical drugs, including: i) improved usability, which affects treatment, compliance and, consequently, improves therapeutic results; ii) safety; iii) controllable drug delivery; iv) skin barrier build-up and hydration; and v) enhanced clinical efficacy.

Background: Conventional treatments for atopic eczema include topical corticosteroids (TCS) and emollients. Pimecrolimus, an immunosuppressant, was licensed in the U.K. in 2003 as an alternative treatment of mild to moderate atopic eczema., Objectives: To assess the cost-utility of pimecrolimus as a treatment for mild and moderate atopic eczema when compared with conventional treatments which use TCS and emollients., Methods: A Markov state-transition model was developed to represent the cyclical nature of atopic eczema and provide an economic analysis of cost-utility for treatment alternatives from the perspective of a third party payer (U.K. National Health Service). A range of methods was used to obtain data for transition probabilities, costs and quality of life. These included a systematic review of published effectiveness data, expert opinion, and a utility study conducted by the authors. Separate cohort analyses were modelled to distinguish between children and adult populations and between differing treatment patterns for facial and body eczema. One-way sensitivity analyses and probabilistic sensitivity analysis (using Monte-Carlo simulation) were performed., Results: Baseline cost-utility outputs from the model show that, in all tested scenarios, TCS dominate pimecrolimus (i.e. TCS are both cheaper and more effective). However, the differences in benefits between treatments output by the model are very small. Sensitivity analyses highlight the importance of cost variations in pimecrolimus. Where pimecrolimus is compared with emollient only it is probably cost effective at a willingness-to-pay threshold of 30 000 UK pounds per quality-adjusted life year., Conclusions: There are likely to be few situations in which the use of pimecrolimus for the treatment of atopic eczema can be justified on economic grounds. Exceptions are likely to be in cases where TCS have been shown to be ineffective, unacceptable due to adverse events, or where a patient is unwilling to accept TCS treatment despite appropriate education and support and emollient alone is the alternative clinical option.

Objectives: To consider the effectiveness and cost-effectiveness of pimecrolimus for mild to moderate atopic eczema and tacrolimus for moderate to severe atopic eczema compared with current standard treatment in adults and children., Data Sources: Electronic databases. Experts and the manufacturers of these agents were also approached for information., Review Methods: The systematic review was carried out using standard methodological guidelines and a stringent quality assessment strategy. A state transition (Markov) model was developed to estimate cost--utility of tacrolimus and pimecrolimus separately, compared with current standard practice with topical corticosteroids, (a) as first-line treatment and (b) as second-line treatment. Pimecrolimus was also compared to emollients only., Results: The pimecrolimus trial reports were of varying quality; however when compared with a placebo (emollient), pimecrolimus was found to be more effective and to provide quality of life improvements. There is very little evidence available about pimecrolimus compared with topical corticosteroids. Compared with a placebo (emollient), both 0.03% and 0.1% tacrolimus were found to be more effective. Compared with a mild corticosteroid, 0.03% tacrolimus is more effective in children as measured by a 90% or better improvement in the Physician's Global Evaluation (PGE). Compared with potent topical corticosteroids, no significant difference in effectiveness is seen with 0.1% tacrolimus as measured by a 75% or greater improvement in the PGE. Minor application site adverse effects are common with tacrolimus. However, this did not lead to increased rates of withdrawal from treatment in trial populations. The PenTag economic model demonstrates a large degree of uncertainty, which was explored in both deterministic and stochastic analyses. This is the case for the cost-effectiveness of pimecrolimus and tacrolimus in first- or second-line use compared with topical steroids. In all cases immunosuppressant regimes were estimated to be more costly than alternatives and differences in benefits to be small and subject to considerable uncertainty., Conclusions: There is limited evidence from a small number of randomised controlled trials (RCTs) that pimecrolimus is more effective than placebo treatment in controlling mild to moderate atopic eczema. Although greater than for pimecrolimus, the evidence base for tacrolimus in moderate to severe atopic eczema is also limited. At both 0.1% and 0.03% potencies, tacrolimus appears to be more effective than the placebo treatment and mild topical corticosteroids. However, these are not the most clinically relevant comparators. Compared with potent topical corticosteroids, no significant difference was shown. Short-term adverse effects with both immunosuppressants are relatively common, but appear to be mild. Experience of long-term use of the agents is lacking so the risk of rare but serious adverse effects remains unknown. No conclusions can be confidently drawn about the cost-effectiveness of pimecrolimus or tacrolimus compared with active topical corticosteroid comparators. Areas for further research should focus on the effectiveness and safety of the treatments through good-quality RCTs and further economic analysis.

Objective: To determine whether a three day burst of a potent corticosteroid is more effective than a mild preparation used for seven days in children with mild or moderate atopic eczema., Design: Randomised, double blind, parallel group study of 18 weeks' duration., Setting: 13 general practices and a teaching hospital in the Nottingham area., Participants: 174 children with mild or moderate atopic eczema recruited from general practices and 33 from a hospital outpatient clinic., Interventions: 0.1% betamethasone valerate applied for three days followed by the base ointment for four days versus 1% hydrocortisone applied for seven days., Main Outcome Measures: Primary outcomes were total number of scratch-free days and number of relapses. Secondary outcomes were median duration of relapses, number of undisturbed nights, disease severity (six area, six sign atopic dermatitis severity scale), scores on two quality of life measures (children's life quality index and dermatitis family impact questionnaire), and number of patients in whom treatment failed in each arm., Results: No differences were found between the two groups. This was consistent for all outcomes. The median number of scratch-free days was 118.0 for the mild group and 117.5 for the potent group (difference 0.5, 95% confidence interval -2.0 to 4.0, P=0.53). The median number of relapses for both groups was 1.0. Both groups showed clinically important improvements in disease severity and quality of life compared with baseline., Conclusion: A short burst of a potent topical corticosteroid is just as effective as prolonged use of a milder preparation for controlling mild or moderate atopic eczema in children.

It is estimated that 30% of nursing home residents may be faecally incontinent, with those figures rising to 60% for patients in long-stay hospitals (Royal College of Physicians, 1995). Maintaining skin integrity for these patients can be complex. With little clinical information to support carers, choosing a skin care regime that maintains skin integrity for this high-risk group can be difficult. This study aims to compare two recognized skin care regimes, used in the cleansing of patients' skin following an episode of incontinence, and their impact on patients' skin integrity. A total of 93 patients were recruited to the trial from five care of the elderly or dependent service providers. The subjects were randomly allocated to either group A (soap and water; n = 49), or group B (Clinisan (Vernacare); n = 44). Initially, 33 patients in both groups started with healthy skin. However, the results of the final assessment identified only 17 subjects in group A remaining healthy, compared with 27 in group B.

Emollients are essential in the management of dry skin conditions, but are often underused in general practice. Selection depends on the knowledge and experience of the practitioner and patient preference. Careful explanation of the use and variety of emollients will assist successful management of dry skin conditions.

Emollients soothe and hydrate the skin. These products are the mainstay of treatment for contact dermatitis. Nurses do not need to be experts in dermatology but they do need to understand the principles and be able to advise on treatment options.

Some of the more common features of psoriasis are reviewed here as an introduction to therapeutic modalities that can be employed in the management of this disorder in the New Zealand situation. An approximate indication of costs for the various therapies is included. This article is sponsored by the therapeutics section of the Department of Health, however, the views of the contributors do not necessarily reflect departmental policies.