Burden of Disease, Unmet Needs in the Diagnosis and Management of Atopic Dermatitis: An Indian Expert Consensus

Figures & data

Table 1 Consensus Statements

Consensus Statements	Voting Results^a	Consensus
Burden of Disease
Practicing clinicians are largely cognizant of the significant psychological burden AD has on patients. However, there is a need for more sensitization for estimating the psychological burden	10/10	100%
A proactive communication, follow-up calls, patient counseling, and education can improve treatment compliance and strengthen patient-physician relationship	10/10	100%
Due to the chronic, recurrent nature of the disease, cost incurred for the treatment of moderate-to-severe AD is comparable to other chronic illness such as diabetes	10/10	100%
Multiple factors such as reducing frequency of hospital visits, cost of medication, and providing social cover can reduce the cost of care; however, prompt referral to the specialist in the early stage can reduce humanistic and economic burden of disease	10/10	100%
Diagnosis and Severity of Disease
It is important to consider the burden of symptoms while assessing severity of the disease. Additionally, there is a strong need to consider the psychological, social, and monetary impact the disease has on the patient and family members/caregivers/parents	9/10	90%
True Estimation of AD is Difficult due to Inconsistent Definition
There is a need for a clear and simple definition of AD to estimate its true prevalence in India	10/10	100%
There is a lack of countrywide, multicenter survey/study that makes it difficult to estimate the true prevalence of AD in India	9/9	100%
Etiopathogenesis of AD
A combination of environmental, genetic and familial factors is responsible for AD	10/10	100%
A complex interplay of urbanization, environmental (the effect of weather and humidity), and diet may contribute towards the region-specific differences in AD	10/10	100%
Other Statements with ≥75% Agreement
In majority of cases, AD is underestimated/underdiagnosed in India	8/10	80%
Some of the minor symptoms from Hanifin and Rajka criteria are non-significant in the Indian context due to a combination of clinical and genetic factors, along with inconsistencies in the definition of AD, and a higher proportion of patients presenting with mild disease	7/9	77%
Patients approach clinicians once home remedies or other treatments do not provide respite; however, this could be specific to the location of practice but largely remains case-specific	8/9	88%
The prevalence of childhood AD is more than adolescent/early adulthood AD	8/10	80%
Duration of interaction with a patient is case-specific and depends on the severity of the disease, age of patient, and other patient-specific factors	7/8	87%
Regardless of the age of patients, both (adult or children) are equally non-compliant to TCS treatment as suggested by the clinician and hence require counseling and awareness	7/9	77%
Following SCS treatment, Indian patients with AD rarely experience glaucoma, cataract, osteoporosis, and adrenal insufficiency	7/9	77%

Note: ^aNumber of experts who agreed/ number of experts who voted.

Abbreviations: AD, atopic dermatitis; SCS, systemic corticosteroids; TCS, topical corticosteroids.

Figure 1 Classification of AD based on severity. Data from^25,47.

Abbreviations: AD, atopic dermatitis; EASI, The Eczema Area and Severity Index; SCORAD, Scoring Atopic Dermatitis.

Table 2 Studies Determining Prevalence of AD in India

Author (Year)	Age Group	N	Study Duration	Prevalence	Severity of AD
					Mild	Moderate	Severe
Dhar (2002)^Citation27	0 months-13 years	18,285	April 2000-March 2001	0.55%	54%	27%	19%
Sarkar (2004)^Citation42	0 months-12 years	418	January 2000-August 2001	29.9%	Infantile AD
					30.8%	57.7%	11.5%
					Childhood AD
					44.4%	56.5%	3.0%
Karthikeyan (2004)^Citation43	≤14 years	2100	May 2001-June 2002	8.6%	Not reported
Odhiambo (2009)^Citation11, a	6–7 years and 13–14 years	385,853 and 663,256	1999–2004	2.7%^b 3.6%^c	Not reported
Kumar (2012)^Citation12	0 months-15 years	1829	January 2010-December 2011	Overall: 7.21%	42.4%	44.7%	12.9%
Sehgal V (2015)^Citation13	2–12 years	100	May 2010-December 2011	Overall: 0.98%	Not reported
Jawade (2015)^Citation14	≤14 years	1021	June 2009-June 2010	20.61%^d 15.61%^e	Not reported
Upendra (2017)^Citation15	6–16 years	1943	-	4.6%	6–10 years
					82.4%	15.7%	1.9%
					10–16 years
					87.2%	10.3%	2.5%

Notes: ^aISSAC study; ^b6–7 years; ^c13–14 years; ^d<1 month age group; ^e>1 month to 14 years.

Abbreviations: AD, atopic dermatitis; ISAAC, The International Study of Asthma and Allergies in Childhood.

Table 3 Etiology of AD

Genetic Factors

● Loss of function mutations in the FLG gene is the strongest known genetic risk factor.^Citation7

o Associated with skin barrier impairment, increased TEWL, greater penetration of allergens, and increased risk of persistent AD.^Citation7

● In a prospective, case-control study, the prevalence of FLG mutations were common in north Indian patients with hand eczema than controls (33.7% vs 3.5%).^Citation44

o Mutations in S2889X constituted 96.4% of all FLG mutations.

o FLG mutations were associated with irritant contact dermatitis with or without atopy, allergic contact dermatitis with or without atopy, and idiopathic subtypes.

● Malassezia yeast in AD acts as an allergenic aggravating factor provoking recurrent episodes of AD symptoms.^Citation45

o A prospective study in India has shown higher isolation rate of Malassezia yeast in cases compared to controls (63.1% vs 52.6%).

Familial Factors

● Approximately 70% of patients are estimated to have a positive family history.^Citation1,Citation7

o 2- to 3-fold increased odds when one parent is affected.

o 3- to 6-fold if both the parents are affected.

o 1.5-fold if one of the parents suffer from any atopic disease.

● Studies conducted in India have shown a wide variation in the proportion of patients with personal (15–54%) and family history (36–65%) for AD.

o A study conducted in north India reported that the childhood AD group had patients with personal history (15.37%), family history (36.37%), and both personal and family history (7.36%) of atopy.^Citation46

o In another study, 54% of patients had personal history and 65% of patients had family history of atopy.^Citation27

o Sarkar et al reported that 42.3% from infant group and 35.35% from childhood group had family history of atopy while in the childhood group 7.07% had personal history, and 2.02% had both personal and family history of atopy.^Citation42

Environmental Risk Factors^Citation1

● Air temperature and humidity

● Tobacco smoke

● Low UV light exposure

● Food allergies

● Living in an urban setting

● Consuming a diet high in sugars and polyunsaturated fatty acids

● Repeated exposure to antibiotics before 5 years of age

● Small family size

● High education level of household

● Studies conducted in India showed eczema aggravation in winters due to decreased moisture than summers.

o A study in north Indian children showed that 62% of patients had exacerbations in winter while 17% experienced it in summer.^Citation42 Similar findings were observed by Dhar et al among infants. (67.14% vs 23.36%) and children (58% vs 32.9%) in winters and summers, respectively.^Citation46

o On the contrary, a study in eastern India reported that a higher proportion of patients had aggravation in summer compared to winter (40% vs 15%).^Citation27

Abbreviations: AD, atopic dermatitis; FLG, filaggrin; TEWL, transepidermal water loss; UV, ultraviolet.

Figure 2 Pathogenesis of AD. Data from ^1,29,48.

Notes: *Lipids include cyclic adenosine monophosphate, cathelicidin and beta-defensins. Epidermal barrier proteins include FLG, keratins, loricrin, involucrin and intercellular proteins

Abbreviations: AD, atopic dermatitis; CD, cluster of differentiation; FLG, filaggrin; GM-CSF, granulocyte-macrophage colony-stimulating factor; Ig, immunoglobulin; IL, interleukin; S. aureus, Staphylococcus aureus

Table 4 Expert Panel Recommendations on the Management of AD in India

Burden of AD

● Educating medical students on enhanced communication skills in addition to considering symptomatic presentation

● Verbal counseling of family members/caregivers/senior members

● Proactive follow-up

Prevalence of AD

● A nation-wide survey that should be/have:

o Multicentered and multidisciplinary (including dermatologists, allergy specialist, pediatricians)

o Delphi questionnaire to obtain real-world data

o Conducted in winter and summer

o A simple and clear definition of AD

o A well-defined inclusion criterion

Etiopathogenesis of AD

● For better understanding of “hygiene hypothesis”, a high-powered nationwide study including all the factors contributing to AD should be considered

● Consider the role of antibiotics and other aspects of immunology responsible for dysbiosis

Diagnosis and Disease Severity of AD

● A simple and highly sensitive diagnostic criterion

● Consider DLQI in routine management of AD

● Severity scoring should also include psychological, social, and monetary impact of the disease on the patient and family members/caregivers/parents in addition to burden of symptoms

Treatment of AD

● Proper treatment protocols and longitudinal monitoring to assess treatment-associated side effects

● Regulating the use of TCS among general practitioners and other clinicians

● Rigorous counseling sessions for patients/caregivers while prescribing a steroid

Abbreviations: AD, atopic dermatitis; DLQI, Dermatology Life Quality Index; QoL, quality of life; TCS, topical corticosteroids.

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