Education Needs Are High for Atopic Dermatitis Patients

One of the lead characters in the HBO smash hit Game of Thrones has been told by several characters: “You know nothing, Jon Snow.” Unfortunately, a similar quote could be used to describe patients with atopic dermatitis (AD). At the very least, the quote could be modified to, “You know very little.”

While the causes of AD (commonly referred to as eczema) are still unclear, treatments for it are well-established. What is slightly less well-established is an effective way to get patients to adhere to those treatments. This is a challenge across the medical care spectrum, of course, but it can be particularly acute for atopic dermatitis patients, in part because the condition comes and goes, and in part because its long-term consequences may not be well-understood by those who suffer from the condition.

A recent paper in Postᶒpy, the journal of the Polish Society of Allergology, looked at patient compliance with recommended instructions of atopic dermatitis therapy. They found evidence of a pretty woeful record.

The research involved 141 AD patients and their compliance with a common treatment method, glucocorticosteroids (GCSs). During periods of AD exacerbation, study patients had lesions covering 10% to 50% of the skin surface area. To put it simply, these are patients with a significant course of illness. Outpatient treatment in specialized clinics was given to 93% of the study subjects. Slightly less than half of participants attended regular medical control examinations.

Despite that fact that 91.5% of patients declared that they were informed about the principles of topical treatment and the type of GCSs used by their attending doctor, the Postᶒpy study revealed some alarming results:

• Two-thirds of patients obtained no information about the anti-inflammatory potential of GCSs.
• GCSs were applied more frequently than twice daily by 36.4% of the patients.
• A stunning 130 patients introduced their own modifications to the instructions concerning GCSs use; of those, 37.7% changed the site of application, 58.5% prolonged the duration of application, and 49.5% shortened it or occasionally temporarily withdrew the prescribed drug.
• None of the patients in the study were aware of the fingertip unit method of dose assessment.
• A significant percentage (43.3%) of AD patients did not perform any care procedures that enhance that can lessen the course of AD, including regular baths and applying emollients.

The study authors note that, “Although the majority of patients… [received] information about the type of applied drugs from the attending doctors, the knowledge of their potency was varied and incomplete.” Patients generally knew more about substances with very low potency of action—such as hydrocortisone—which has for some time been available over the counter.

Adherence to therapy as prescribed is important for patients with AD, because topical GCS application can cause the development of significant side effects, such as skin atrophy, vascular damage, steroid-induced acne, and contact hypersensitivity. Long-term usage is associated with more severe side effects, including depression and psychiatric disorders. Safe application involves not just using the correct dose the correct number of times per day, but also the method of application, because the medication penetrates the skin better in some areas than others. As the authors note, “Daily multiple application of a GCS can also lead to a blockade of cytoplasmatic receptors for these drugs and can cause paradoxical lack of response to the treatment.”

Prior to prescribing treatment with GCSs, healthcare professionals should inform patients about the maximal weekly dose, proper area of application, duration of treatment, and potential adverse effects.