European dermatologists have diverse prescribing practices when treating adults with moderate to severe atopic eczema (AE), with on-label ciclosporin, phototherapy, and off-label systemic therapies the most commonly prescribed first-line treatments, according to study research published in the British Journal of Dermatology.

Numerous promising therapies have been introduced for the treatment of moderate to severe AE in. To gain insight into the prescribing practices of dermatologists treating adult patients within this population, as well as the factors that influence these prescribing practices, investigators conducted an online, anonymous, multiple-response survey of members of the European Academy of Dermatology and Venereology and national societies. The European Treatment of Atopic Eczema Taskforce (TREAT) survey included questions on participant characteristics (including individual clinical practices) and the use of systemic therapies and phototherapies. Dermatologists were asked to make decisions for treating patients with AE not adequately controlled by standard and optimized topical treatments, and who were not having an acute flare.

In the 30 European countries, 65.9% (238 of 361) of dermatologists contacted completed the survey, and 229 of these met the inclusion criteria (4 were excluded for being based in the UK, 4 for not prescribing phototherapy or systemic therapies, and 1 for being a general practitioner). Of these, 41.5% (95 of 229) of dermatologist respondents indicated phototherapy was their first-line therapy choice for moderate to severe AE, followed by day care therapy (39.3%; 90 of 229), and systemic therapy (61/229; 26.6%). Preferred second-line therapies were systemic therapy (49.8%; 114 of 229) and phototherapy (38.4%; 88 of 229).

Of clinicians prescribing phototherapy (84.7%; 194 of 229), narrow-band ultraviolet-B (UVB) was preferred as the first-line therapy by 80.9% of respondents, followed by broad-band UVB (BB-UVB) (7.7%), and ultraviolet-A plus ultraviolet-B (UVAB) therapy (6.2%). Psoralen and ultraviolet-A was the most frequently prescribed second-line treatment (21.6%), followed by BB-UVB (16.5%) and UVAB (14.4%).

Of respondents, 95.2% (218 of 229) prescribed systemic therapy, with preferred first-line therapies being ciclosporin (54.1%), oral corticosteroids (32.6%), and methotrexate (30.7%). Dermatologists primarily used personal experience for guidance when prescribing phototherapy and/or systemic therapy. Only 5.5% (12 of 229) of participants prescribed azathioprine as a first-line therapy and only 1.8% (4 of 229) prescribed mycophenolate, citing a lack of personal experience as the reason. For second-line therapies, 30.7% prescribed azathioprine; and for third-line therapies, 30.7% prescribed azathioprine and 22.0% prescribed mycophenolate acid. Methotrexate was mostly prescribed as a second-line (40.8%) or third-line treatment (15.6%).

The investigators conclude that although the results may have been influenced by diversity of respondents (fewer than 5 respondents from most countries), by respondents mainly being based in academic hospitals, and by selection bias and recall bias, these findings do show that next to the on-label use of ciclosporin, phototherapy and off-label systemic therapies are most often chosen as first-line treatment in adults with moderate to severe AE. They also point out that therapies will continue to change as new treatments are introduced, “it might be very interesting to re-evaluate the prescribing practices in moderate-to-severe AE in the future and see how these changes have influenced patient care. This is even more interesting in the future as our understanding of the molecular basis of AE is advancing and phenotypes and biomarkers that characterize these phenotypes are being unravelled.”

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Disclosure: Several study authors declared affiliations with the pharmaceutical industry. Please see the original reference for a full list of authors’ disclosures.

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Reference

Vermeulen FM, Gerbens LAA, Schmitt J, Deleuran M, Irvine AD, Logan K, et al; TREAT Registry Taskforce. The European TREatment of ATopic eczema Taskforce (TREAT) Survey; prescribing practices in Europe for phototherapy and systemic therapy in moderate-to-severe adult atopic eczema patients [published online February 18, 2020]. Br J Dermatol. doi: 10.1111/bjd.18959