Despite Guidelines, Systemic Corticosteroids Remain Widely Prescribed for Atopic Dermatitis

Christopher Bunick, MD, PhD

Credit: Yale School of Medicine

While there are clinical guidelines which advise health care providers and patients against the use of systemic corticosteroids (SCS) for atopic dermatitis, new findings suggest they remain widely prescribed within the US for this skin condition.^1,2

These new findings suggest that approximately 1 in 5 individuals known to have atopic dermatitis is prescribed a systemic corticosteroid. This research was presented at the 44th Annual Fall Clinical Dermatology Conference in Las Vegas, Nevada, in October 2024. The research itself was authored by investigators such as Christopher G. Bunick, MD, PhD, of the department of dermatology at Yale School of Medicine.

“Food and Drug Administration-approved advanced systemic treatments, including injectable biologics and oral Janus kinase inhibitors, are available for moderate-to-severe AD,” Bunick and colleagues wrote. “Systemic corticosteroids (SCS) have broad, non-specific immunosuppressive effects that do not target the immune pathways involved in AD, leading to a substantial risk of serious adverse events, even with short-term use.”²

This new research was conducted to evaluate the real-world utilization and duration of systemic corticosteroid exposure among those in the US with this condition following the introduction of advanced therapies into clinical settings.

Guidelines by the American Academy of Dermatology (AAD) and the International Eczema Council (IEC) consensus had been recently released, cautioning against the routine implementation of SCS. The investigators of this study suggest that this was specifically due to their unfavorable benefit/risk profile.

In fact, the guidelines note that use of SCS should be limited to special situations, some of which could be circumstances requiring acute severe flare control. Other circumstances might be when they are implemented as a short-term bridge to other systemic options or when no other options are accessible.

Bunick et al. conducted their retrospective analysis by reviewing healthcare claims drawn from the Optum Clinformatics Data Mart database in the US. They looked at data from the period between March 2017 - March 2024, specifically identifying patients in the age range of 12 years and older with diagnosed atopic dermatitis.

These subjects would also have to have begun either oral or intramuscular SCS administration. Those deemed eligible for trial inclusion had to maintain continuous health insurance for 1 year at least prior to and a year following SCS therapy.

For the purposes of ensuring SCS treatment specifically targeting atopic dermatitis, the research team restricted their analysis to those who either had a diagnosis recorded in an inpatient visit or documented in 2 separate outpatient visits within the prior half a year.

The team tracked the study subjects until either termination of insurance, the conclusion of the data period, or subject death. SCS exposure length was classified by the investigators into either shorter-term, medium-term, or longer-term categories, based on both clinical research and observed patterns in their data.

Between March 2017 - March 2024, full requirements for inclusion in the team’s research were met by 29,994, so they began SCS treatment. Although it was concluded by the investigators that 34.4% of those with atopic dermatitis initially appeared to utilize SCS, the figure dipped to 20.0% when they limited the cohort to subjects without additional conditions that typically lead to SCS prescriptions.

Bunick and colleagues noted that those in the patient cohort were 59.7% female, adding that they maintained an average age of 50.4 years. The majority of prescriptions for SCS were shown to have been orally-administered.

Among subjects prescribed SCS, the research team reported that 67.7% had been determined to be short-term users, 8.5% medium-term, and 23.9% longer-term. The team further noted that among those using SCS long-term, 83.9% had been over 30 years old. This was compared to 80.3% among those using medium-term and 72.8% using short-term.

The investigators also highlighted that dermatology visit rates showed consistency across all SCS usage cohorts. Despite this conclusion, they reported slightly higher rates among longer-term users of both biologic and conventional systemic immunosuppressant usage. This was compared to the rates of medium- and short-term SCS (3.3% versus 3.2% and 2.5%, respectively, and 2.6% versus 1.9% and 1.2%, respectively).

References

1. ^{Bunick C, Vleugels R, D’Andrea E, et al. Utilization and Duration of Systemic Corticosteroid Exposure in Atopic Dermatitis Patients After the Introduction of Advanced Therapies: A Population-Based Study From the United States. Presented at the 2024 Fall Clinical Dermatology Conference. Las Vegas, Nevada. 24-27 October.}
2. ^{Davis DMR, Drucker AM, Alikhan A, Bercovitch L, Cohen DE, Darr JM, Eichenfield LF, Frazer-Green L, Paller AS, Schwarzenberger K, Silverberg JI, Singh AM, Wu PA, Sidbury R. Guidelines of care for the management of atopic dermatitis in adults with phototherapy and systemic therapies. J Am Acad Dermatol. 2024 Feb;90(2):e43-e56. doi: 10.1016/j.jaad.2023.08.102. Epub 2023 Nov 7. PMID: 37943240.}