Patient Evaluation Scarce Among Dermatologists in France Treating Atopic Dermatitis

A survey in France found that systemic medications are used by only half of dermatologists in treating atopic dermatitis (AD) and that methotrexate is used more than cyclosporine, likely due to greater familiarity with the drug and the absence of a requirement for an initial hospital prescription.

The survey results, published in Clinical, Cosmetic and Investigational Dermatology, showed that cyclosporine was used by only 46.9% of dermatologists even though it is the only systemic medication approved for AD in France.

Methotrexate is used more often (54%) despite its lack of marketing authorization for AD. It has the advantage of often being easier to prescribe because only doctors who practice at least part time in a hospital are permitted to initiate cyclosporine therapy, the authors said.

Dupilumab (Dupixent), a monoclonal antibody, is used more often (56.4%) than methotrexate and cyclosporine, despite France permitting its initiation only in a hospital setting.

A total of 305 dermatologists responded to the survey, 57% of whom had hospital activity and 43% who were in private practice.

Prior research shows underprescribing of systemic treatments, the authors said, with a 2017 study showing that although 73% of patients had moderate to severe AD, only 8% were receiving systemic treatment. A survey in the United Kingdom also showed hesitancy to prescribe systemic treatments—just 37.4% of dermatologists do—with azathiorprine (Azasan; 51.2%) and corticosteroids (42.9%) used more often.

A lack of experience with cyclosporine (79.2%) was the most common reason for not prescribing the drug, according to the survey. Other reasons were lack of information about the drug (52.6%), the need for a hospital prescription (31.2%), and no eligible patients (24.7%). The survey did not address the safety profile of cyclosporine, but a separate 2020 study indicated dermatologist concerns about liver toxicity, hypertension, and infection.

However, when cyclosporine was prescribed, it was used as a first-line treatment in 77.2% of cases and a second-line treatment in 31.6% of cases. It was given for moderate AD by 46.3% of dermatologists and by 99.3% for severe AD.

The leading reason for not prescribing methotrexate was its lack of approval for AD (47.4%), lack of eligible patients (46.7%), lack of information (39.3%), and lack of experience with the drug (25.2%). A total of 2.1% of dermatologists prescribed other systemic treatments, and 9.8% prescribed corticosteroids.

When methotrexate was used, it was a first-line systemic treatment and a second-line treatment in 47.4% of cases each. It was also used in 26.6% of cases where dupilumab failed.

The present survey also shows that a majority of dermatologists do not use assessment scoring systems before determining how to treat AD, making it more difficult to gauge the severity of the disease and the effectiveness of treatments. The survey showed 56.9% and 50.5% did not perform evaluation scoring before prescribing cyclosporine and methotrexate, respectively.

The wider use of dupilumab indicates a willingness to try new treatments for those with moderate to severe symptoms, the authors said.

Many are under development in what they call the dawn of a therapeutic revolution, and they include biotherapies targeting interleukin (IL) 13 (tralokinumab, lebrikizumab) or IL-31 (nemolizumab) and Janus Kinase inhibitors (baricitinib, upadacitinib [Rinvoq], and abrocitinib).

Adult AD has an estimated prevalence of 4.65% in France, with 68% of patients having moderate to severe symptoms.

Reference

Fougerousse AC, Jacobzone C, Mery-Bossard L, et al. Use of systemic medications for treating adult atopic dermatitis in France: results of a practice survey. Clin Cosmet Investig Dermatol. 2021;14:179-183. doi:10.2147/CCID.S300402