Iatrogenic Burden of Atopic Dermatitis

Abstract

The management required for atopic dermatitis (AD) may worsen patient burden, thereby resulting in iatrogenic burden, that is, morbidity caused by medical treatment. We sought to describe the iatrogenic burden of AD and conducted a narrative review of key areas that clinicians can address to minimize it. Clinicians should think strategically about itch trigger avoidance, encourage slow incorporation of lifestyle changes, and emphasize step-up therapy when avoidance becomes too burdensome. Out-of-pocket treatment costs should be incorporated into shared decision making to balance affordability, preference, efficacy, and safety. Polypharmacy should be minimized by eliminating ineffective, nonevidence-based, and redundant therapies while appropriately stepping up to advanced therapy. Clinicians should take adequate time to communicate, the impact of AD on quality of life, and incorporate evidence-based guidelines. The multidimensional nature of AD requires a dynamic approach. Future guidelines should incorporate step-up, step-down, and maintenance approaches to reduce treatment burden and improve quality of life.

Figure 1:. Step-up and step-down therapeutic approach to atopic dermatitis.

Basic management should be implemented for all atopic dermatitis (AD) patients and used as primary therapy. Emollients, bathing, and trigger avoidance should be optimized regardless of AD severity. Prescription topical anti-inflammatory therapy, including corticosteroids, calcineurin inhibitors, phosphodiesterase 4 inhibitors, and Janus kinase inhibitors, should be the first consideration when there is an inadequate response to basic management, regardless of AD severity. Different management approaches in these two categories can then be uniquely emphasized based on SDM between healthcare providers and patients. Patients in need of long-term control can be maintained on reactive and/or proactive treatment with prescription topical therapy with a focus on reducing or discontinuing burdensome lower step therapies. Those with adequate control and clear skin should consider a step-down approach to just basic management. Additional step-up therapy with phototherapy, biologics, oral systemic immunomodulators, or acute hospitalization may be required for moderate-severe AD patients who have an inadequate response to prescription topical therapy. If advanced therapies need to be maintained to achieve long-term control, concomitant reduction of lower step therapies (e.g., multiple different prescription topical therapies, careful avoidance of several itch triggers) may reduce the overall treatment burden and improve patient health-related quality of life. Eventually, those who achieve adequate control and clear skin in response to systemic therapy may be able to discontinue that therapy and step-down to a management plan centered on prescription topical anti-inflammatory therapies and basic management. *These therapies are currently under review by the U.S. Food and Drug Administration with final decision expected in 2021. # These therapies are not approved by the U.S. Food and Drug Administration and their use in atopic dermatitis is considered off-label.