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Patient Management

Managing expectations

Steroid responsive dermatoses may be managed in primary and/or secondary care. In mild cases, over the counter treatment and skin care products may be sufficient, but in moderate or more severe cases, prescription medicines will be required (supervised by a healthcare professional). In addition, it is important to optimise patient–physician interactions, focus on managing patients holistically, and manage any co-morbidities which arise, in order to optimise patient care.

Treatment decisions not only involve medicines, but can also involve skin care and lifestyle changes that can affect daily routines, so it is important that the treatment plan is tailored to the patient’s needs. 1It is therefore essential that any treatment decisions are joint decisions involving the patient, their families and the multidisciplinary team. This enables the patient’s specific emotional and lifestyle needs to be taken into consideration and ensures that the most appropriate treatment is chosen.

Defining the treatment goals

Although atopic dermatitis (AD) cannot be cured, appropriate skin care can improve skin barrier function, reducing susceptibility to flares. 2
Treatment is also important in providing effective control of AD: 12

  1. Prevent the AD from getting worse
  2. Calm the skin, relieve pain and itching
  3. Reduce emotional stress
  4. Reducing skin inflammation (redness and swelling)
  5. Clear/prevent infection
  6. Loosen and remove scaly lesions
  7. Prevent new lesions from forming

Psoriasis is also not curable. While the ultimate treatment goal for patients with psoriasis is the complete clearance of skin lesions, this is not always achievable with currently available treatment options. 34

When defining the treatment goals, it is important to match the patient expectations with practical considerations. In all cases of psoriasis, the aim is to maximise the efficacy and the patient’s quality of life, while minimising the side effects. 4

The major treatment goal for psoriasis is generally defined as a ≥75% reduction in psoriasis area and severity index (PASI), after induction treatment, with the reduction on PASI score continuing throughout maintenance treatment. 3

Below is a list of treatment goals that are important to take into consideration when making treatment decisions for patients with chronic skin conditions. 24–6

Treatment outcomes goal    How to achieve goal
Reduce symptoms

 
  • Appropriate medication
  • Patient education
Reduce number and 
severity of flares
 
  • Appropriate medication
  • Patient education

Prolong periods 
between flares

 

  • Appropriate medication
  • Patient education
Management goals    How to achieve goal
Improve physical well-
being
  • Improvements in skin lesions
  • Patient free of itching
  • Patient pain-free
  • Patient able to sleep better
Improve mental well-
being
  • A clear diagnosis
  • Appropriate therapy
Improve daily working
life
  • Fewer doctor and clinic appointments
  • Less time required for daily treatment
  • Patient able to lead a normal working life
Increase social contact
  • Patient feels more comfortable touching others
  • Patient more comfortable in public
  • Patient able to have more contact with other people
Increase leisure time activities
  • Patient able to participate in normal leisure time activities, including sports, relaxation and hobbies
Increase general
quality of life
  • Patient able to lead a normal daily life
  • Patient more capable in daily life
  • Patient experiences a greater enjoyment of life

Refer to the following patient association websites to gain further understanding of
patient experiences with their disease:

  • International Federation of Psoriasis Associations http://www.ifpa- pso.org/web/page.aspx?refid=42
  • National Eczema Association (US) https://nationaleczema.org/living-with- eczema/personal-experiences/
  • National Eczema Society (UK) http://www.eczema.org/living-with-eczema
  • National Psoriasis Foundation (US) https://www.psoriasis.org/blog
  • Psoriasis Association (UK) https://www.psoriasis- association.org.uk/pages/view/about-psoriasis/resources/patients-speaking

Non-pharmacological interventions

Aside from treating the condition with pharmacological interventions such as TCSs, there are a number of non-pharmacological interventions to support the management of your patient.

Daily care

Atopic dermatitis

Daily skin care that encapsulates cleansing, bathing and emollient use underpins the recommendations of several international guidelines on the management of AD, irrespective of disease severity. 7–10

Mechanical cleansing of skin is important to remove skin debris and eliminate bacterial contaminants in the case of bacterial superinfections; cleansers are available in a variety of non-irritant, low-allergen formulations. 7

The goal of these non-pharmacological approaches is to address skin barrier dysfunction that manifests as dry skin (xerosis) – one of the defining symptoms of AD. 8

Moisturisers combat xerosis and transdermal water loss through the action of emollients, which lubricate and soften the skin; occlusive agents, which retard evaporation of water; and humectants, which are hygroscopic and retain water. 8

Overview of international recommendations for daily skin care 78–10

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Psoriasis

Non-medicated topical emollients are an internationally recognised standard supplemental treatment for psoriasis, recommended for continuous use even when symptoms are controlled 11

Education

Educational interventions disseminate knowledge about the disease and its treatment, equipping the patient with an understanding of the importance of using medication as prescribed in order to achieve optimal management of their condition. 12
It is important that patients with atopic dermatitis are provided with both oral and written information on the skin care regimen recommended by their health care professional, and that any new information is provided at follow-up visits if updates are available, to: 2

  • Keep the patient informed of their treatment plan
  • Allow realistic treatment goals to be established
  • Educate the patient to manage their own condition by encouraging them to avoid irritants, allergens and other triggers to reduce the itch-and-scratch cycle
  • Encourage patients to adhere to their treatment in order to achieve the best possible treatment outcomes

There is a 89% reduction in the severity of AD when optimal education is provided by a specialist dermatology nurse 13

Education delivery platforms include: 12 Multidisciplinary age-structured training programmes, which help children and parents to cope and reduce skin symptoms and need for treatment 1214

  • Eczema workshops, which result in better adherence than conventional dermatologist-led clinics 15
  • Nurse-led interventions and care, which improve the use of topical therapies and severity scores and reduce visits to doctors 16
  • Access to an atopic dermatitis educator (such as a paediatric allergist, dermatologist or psychologist) 17 and structured lay-led self-management programmes (not shown to improve severity scores) 12


In terms of interventional tools, those that involve personal contact or structured programmes such as education schools provide the most benefit to patients12 although digital resources are now more widely used.

In psoriasis, education is recognised as a crucial intervention to empower patients to self-manage their chronic disease and for successful therapeutic outcomes.
However, there is little evidence or guidance for the use of effective educational programmes for patients with psoriasis.
18 Literature reviews confirm the need to educate patients on:

  • Their skin disease and its chronic nature
  • How to control their own disease in the long-term
  • How to obtain a healthy quality of life. 19


Coping and prevention strategies: atopic dermatitis

AD is more common in children living in urban or developed areas compared with
those living in more rural environments.
20Trigger factors that have been identified include: 21

  • Dry skin, which is particularly bad in winter when heating is on, and which can be aggravated by too much bathing and insufficient moisturising
  • Irritants
  • Stress
  • Heat and sweating, which can be aggravated by exercise, too many bedclothes or rapid changes in temperature
  • Infections, particularly Staphylococcal, Molluscum, herpes and fungal infections
  • Allergens such as pollen, pet dander, foods or dust
  • Common food allergens in infants with AD are cow’s milk, eggs, wheat and nuts, and pollen-related allergies are frequently seen in older children and adults. 72223


Strategies for coping with trigger factors might include:
21

  • Moisturise to keep the skin barrier intact
  • Wear breathable clothes and avoiding wool, nylon and stiff materials
  • Avoid sweating e.g. by layering clothes that can be removed, not overheating rooms especially bedrooms
  • Tackle itching with a cool shower followed by moisturising
  • Recognise signs of infection and treat promptly
  • Establish whether there are specific food allergies, such as eggs, milk, peanuts, seafood, soy or wheat, and discuss avoidance tactics with a doctor
  • When suspected, food sensitisations can be identified by skin prick and antibody (IgE) testing; patch testing can also be use 7
  • Keep pets outdoors. Where this is not possible, keep them off beds, rugs and furniture
  • Consider what factors lead to emotional stress and learn to cope with them using techniques such as relaxation, biofeedback, hypnosis and meditation 24


In terms of prevention of AD, this is a highly desirable goal but the evidence for existing primary prevention strategies is inconsistent
. 25

Current strategies for the primary prevention of AD include trying to induce tolerance to allergens in infants and enhancing the impaired skin barrier to reduce skin flares, sensitization and subsequent allergic disease. 25

Suggested primary intervention strategies include: 25

  • Exposing infants to allergens or endotoxins in early development
  • Limiting the use of skin cleansers and liberally using emollients in babies born to parents with allergic disease

Secondary prevention strategies, implemented after AD first appears, can be used to reduce disease severity, decrease the frequency of flares and prevent relapse. These strategies include using intermittent treatments, e.g. once or twice weekly or at weekends, to try and gain control of the disease. It is currently unclear whether the length and intensity of initial remission is an important factor in gaining long-term control of AD, but it is thought that the most effective strategy is to gain and keep control. 25

Coping and prevention strategies: psoriasis

A combination of external triggers and inherited genes are believed to be responsible for psoriasis development. When combined with one or more of the 25 genetic variants known to increase a person’s likelihood of developing psoriasis, the following external triggers may result in psoriasis onset: 26

  • Stress
  • Injury to skin (vaccinations, sunburn, scratches)
  • Medications, including:
    • Lithium aggravates psoriasis in ~50% of people who take it
    • Antimalarials may cause psoriasis flares 2–3 weeks after drug is administered
    • Propanolol (high blood pressure medication) worsens psoriasis in 25– 30% of patients
    • Indomethacin (nonsteroidal anti-inflammatory drug used to treat arthritis) effects are usually minimal if administered correctly, however it has worsened some psoriasis cases
  • Infection
    • In particular, streptococcus infection (strep throat) is associated with psoriasis onset/flares

Although scientifically unproven, the following are considered by patients to be possible psoriasis triggers 26

  • Allergies
  • Diet
  • Weather

There is no way to prevent psoriasis, however steps can be taken to improve symptoms and reduce the number of psoriasis flare-ups. 27Strategies for coping with psoriasis triggers might include: 2829

  • Stress reduction
    • Meditation
    • Exercise
    • Undertaking a course in stress management/meeting with a therapist
  • Itch management
    • Treating psoriasis with prescription medication
    • Keeping skin moisturised (remove scale and flaking)
    • Cold showers and cold packs can offer itch relief
    • Over-the-counter treatments to treat itching
    • Strategies to reduce stress can also minimise itching
    • Prescription treatments – antihistamines, phototherapy, steroids, topical anaesthetics


Optimising topical corticosteroid treatment success

It is important to select the right topical corticosteroid (TCS) for each patient based on clinical judgement and the needs of the patient. 7–9

Factors that are important in optimising treatment decisions, include establishing the right potency of the TCS, choosing the most appropriate formulation and duration of treatment based on the site of disease, age of the patient and safety considerations to ensure patients adhere, and respond well, to their treatment.

Establishing the right TCS potency

In a study conducted in patients with psoriasis, there is evidence to suggest that a recognisable correlation exists between measured potency and therapeutic efficacy of TCSs. 30

TCSs are now categorised by potency in a region-specific manner:

  • In the United States, TCSs are grouped into seven classes from very low/lowest potency (Class VII) to very high (Class I) potency 8
  • In the EU, TCSs are grouped according to potency, but there are only four classes numbered I (mild)–IV (very potent) 7
  • Other countries and regions have similar designations 93132

Potency classification systems

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The majority of key branded TCS products are classified as potent (EU classification). *33,34

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Different formulations of key branded TCS products according to US potency classifications: *835

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Choosing the right formulation and application

The percutaneous absorption and efficacy of TCSs can be increased when they are used:

  • Under occlusive dressings (e.g. wet wraps, which may be particularly useful for symptom resolution in severe paediatric cases)7936
  • On the face and in intertriginous (naturally occluded) areas 36

Drug effectiveness can also be significantly affected by the vehicle choice, due to the extent of penetration or absorption of the active agent. 3738

Ointments Spread easily; suitable for dry or lichenified skinn 93738
Creams Greater cosmetic appeal; suitable for weeping lesions and flexural or genital areas 9 3738
Lotions Penetrate easily; useful for hair-bearing areas 93738
Gels Dry quickly; useful for hair-bearing areas as they do not cause matting 38
Foams/ shampoos For scalp; spread readily and useful for hair-bearing areas 38

Safety considerations for TCS treatment success

Striking a balance between efficacy, potency and safety is a key consideration in the selection of TCSs.39 Due to the mechanism of action of TCSs, the receptors that result in clinical efficacy are also responsible for the manifestation of adverse effects. 40 Local side-effects have been found to be more prevalent than systemic reactions. 3940

Local side effects 3940 Systemic side effects 3940
  • Skin atrophy
  • Telangiectasia
  • Striae
  • Purpura
  • Contact dermatitis
  • Rosacea
  • HPA axis suppression (with medium- and high-potency CSs)
  • Cushing’s syndrome

In 2012, the German Society of Dermatology published a therapeutic index (TI) describing the balance between the efficacy of a TCS and its adverse effects. 41

  • A high TI is desirable and combines high potency with a low incidence of systemic and local adverse effects 42
  • Newer molecules, such as fluticasone propionate, methylprednisolone aceponate, mometasone furoate, hydrocortisone butyrate and prednicarbate, demonstrate a favourable risk–benefit ratio, and have a TI of around 2 (the highest TI identified for any TCS) 4243
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39, 42, 43

Treatment adherence is a major factor in the response to treatment
Efficacy of TCSs is often hampered by poor patient adherence.
44This may be due to: 45

  • Lack of efficacy
  • Side-effects
  • Inconvenience
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44,46

Psoriasis patients can: 44

  • Experience little improvement from topical therapy, or
  • improve temporarily but then experience subsequent treatment failure

In clinical use, adherence to treatment is thought to have far more impact on likely success than are small differences in drug delivery. 44Patient education including eczema workshops and nurse-led interventions have been shown to improve the use of topical therapies and have a positive impact on patient adherence (see Section 8 for more information). 1647

Patient resources

Patient information leaflets

Download important information for your patients below…

  • Topical corticosteroid patient appropriate usage brochure
  • Topical corticosteroid patient appropriate usage poster

Patient support groups

Patient forums

References:

  1. Atopic dermatitis: Diagnosis, treatment, and outcome. Available at: https://www.aad.org/dermatology-a-to-z/diseases-and-treatments/a---d/atopic- dermatitis/diagnosis-treatment (Last accessed August 2015)

  2. Nicol NH. Pediatr Nurs 2011;37:295–301

  3. Mrowietz U, et al. Arch Dermatol Res 2011;303:1–10

  4. Pardasani AG, et al. Am Fam Physician 2000;61:725–33

  5. Balkrishnan R, et al. Arch Dis Child 2003;88:423–7

  6. Blome C, et al. Contact Dermatitis 2009;61:39–45

  7. Ring J, et al. J Eur Acad Dermatol Venereol 2012;26:1045–60

  8. Eichenfield L, et al. J Am Acad Dermatol 2014;71:116–32

  9. Rubel D, et al. J Dermatol 2013;40:160–71

  10. Sanchez J, et al. Revista Alergia México 2014;61:178–211

  11. Menter A, et al. J Am Acad Dermatol 2009;60:643–59

  12. Ring J, et al. J Eur Acad Dermatol Venereol 2012;26:1176–93

  13. Cork MJ, Danby S. British J Dermatol 2003;149:582–589

  14. Staab D, et al. BMJ 2006; 332:933–38

  15. Moore EJ, et al. Australas J Dermatol 2009;50:100–6

  16. Courtenay M, Carey N. J Clin Nurs 2007;16:122–8

  17. Ricci G, et al. Paediatr Dermatol 2009;26:1–5

  18. Larsen MH, et al. Patient Educ Couns 2014;94:158–69

  19. Bostoen J, et al. Br J Dermatol 2012; 167:1025–31

  20. Merck Manuals: Atopic Dermatitis. Available at: www.merckmanuals.com/professional/dermatologic_disorders/dermatitis/atopic_dermatiti s.html (Last accessed September 2015)

  21. National Eczema Association: Trigger factors for AD. Available at: https://nationaleczema.org/eczema/child-eczema/atopic-dermatitis-in-children/trigger- factors/ (Last accessed September 2015)

  22. Werfel T, Breuer K. Curr Opin Allergy Clin Immunol 2004; 4:379–85

  23. Breuer K, et al. Allergy 2004;59:988–94

  24. National Eczema Association: Coping with AD. Available at: https://nationaleczema.org/eczema/treatment/psychodermatology/ (Last accessed September 2015)

  25. Williams HC, et al. Med Rep 2012;4:24

  26. About psoriasis: Causes and triggers. Available at: https://www.psoriasis.org/about- psoriasis/causes (Last accessed September 2015)

  27. Prevention: Psoriasis. Available at: http://www.prevention.com/health- conditions/psoriasis (Last accessed September 2015)

  28. Life with psoriasis: Managing itch. Available at: https://www.psoriasis.org/lifewithpsoriasis/managingitch (Last accessed September 2015)

  29. Life with psoriasis: Stress. Available at:
    https://www.psoriasis.org/lifewithpsoriasis/stress (Last accessed September 2015)

  30. Stoughton RB. Int J Dermatol 1992;31:26–8

  31. Hino H. Asian Med J 2001 44:142–7

  32. Dermnet NZ: Topical steroids. Available at: http://dermnetnz.org/treatments/topical- steroids.html (Last accessed August 2015)

  33. NICE Clinical Guidelines TA81 (2004): Frequency of application of topical corticosteroids for atopic eczema. Available at: http://www.nice.org.uk/guidance/ta81/resources/guidance-frequency-of-application-of- topical-corticosteroids-for-atopic-eczema-pdf (Last accessed September 2015)

  34. Drugs.com: Advantan. Available at: http://www.drugs.com/international/advantan.html (Last accessed November 2015)

  35. Jacob SE, et al. J Am Acad Dermatol 2006;54:723–7

  36. European Dermatology Forum: Guideline on steroids in pregnancy. Available at: http://www.euroderm.org/edf/index.php/edf-guidelines/category/5-guidelines- miscellaneous?download=34:guideline-steroids-in-pregnancy (Last accessed August 2015)

  37. Huang X, et al. J Am Acad Dermatol 2005;53:S26–S38

  38. Ference JD, et al. Am Fam Physician 2009;79:135–40

  39. Morley KW, et al. Curr Opin Pediatr 2012; 24:121–8

  40. Hengge UR, et al. J Am Acad Dermatol 2006;54:1–15

  41. Pilgrim J. Research Review. Available at: www.researchreview.co.nz/getmedia/f371bddf- afcd-462e-9d2b-5f2a1f7c58c8/Advantan-Product-Review.pdf.aspx?ext=.pdf (Last accessed September 2015)

  42. Korting HC, Schöllmann C. J Eur Acad Dermatol Venereol 2012; 26:133–40

  43. Luger TA. Eur Acad Dermatol Venereol 2011; 25:25

  44. Feldman SR, Yentzer BA. Am J Clin Dermatol 2009;10:397–06

  45. Frangos JE, Kimball AB. Expert Opin Pharmacother 2008;9:2001–7

  46. Charman CR, et al. Br J Dermatol 2000;142:931–36

  47. Moore EJ, et al. Australas J Dermatol 2009;50:100–6

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