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Table of Contents
ORIGINAL ARTICLE
Year : 2020  |  Volume : 38  |  Issue : 2  |  Page : 67-80

A study on the knowledge, attitudes, and practices of Asian dermatologists in the management of atopic dermatitis


1 Department of Dermatology, Changi General Hospital, Singapore
2 Department of Dermatology, National Taiwan University College of Medicine, National Taiwan University Hospital, Taipei, Taiwan
3 Department of Paediatrics, Chinese University of Hong Kong, Sha Tin, Hong Kong
4 Department of Paediatrics, Kuala Lumpur General Hospital, Kuala Lumpur, Malaysia
5 Department of Paediatrics, Chulalongkorn University, Bangkok, Thailand

Date of Submission04-May-2019
Date of Decision04-Jun-2019
Date of Acceptance13-Jul-2019
Date of Web Publication29-May-2020

Correspondence Address:
Dr. Siqing Ee
Department of Dermatology, Changi General Hospital
Singapore
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ds.ds_31_19

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  Abstract 


Background: Atopic dermatitis (AD) is a prevalent skin disease in Asia. Attitudes and practice vary among the Asian cities. Objectives: This study aimed to survey similarities and differences in dermatologists' attitudes and practice in Asian cities. Methods: A questionnaire survey was sent to 118 dermatologists in Singapore, Malaysia, Thailand, Taiwan, and Hong Kong. Results: About 30.8% of respondents from Taiwan and 44.4% of respondents from Hong Kong saw most of their patients presenting with severe AD. This is significantly higher than respondents from Singapore, Malaysia, and Thailand (4%–12%). Majority of the respondents would use topical corticosteroids in infants and children with AD. About 55.6% of the respondents from Hong Kong used topical calcineurin inhibitors in AD, which is a significantly lower than the other countries. Top 3 most prescribed antibiotics in infected AD were cephalexin, cloxacillin, and amoxicillin/clavulanic acid combination. Most respondents used oral corticosteroids in severe AD. Many respondents from Singapore and Malaysia use cyclosporin (70%–92%), azathioprine (80%–100%), and methotrexate (72%–75%). Fewer respondents from Thailand, Taiwan, and Hong Kong used cyclosporin (22.2%–59%), azathioprine (0%–66.7%), and methotrexate (8%–25.6%). A large majority of respondents from Singapore, Taiwan, and Malaysia use phototherapy in management of AD (90%–100%). About 24% of respondents from Thailand and 33.3% of respondents from Hong Kong use phototherapy in AD. Conclusion: Compared to the previous study, there is improvement in the proportion of dermatologists in Asia using topical calcineurin inhibitors and phototherapy. This may signify better access to these treatment modalities throughout the region. Educational programs that allow a patient-centered approach should be recommended as an adjunct to medical therapy. The management of AD among Asians requires a holistic approach while considering accessibility and cultural differences.

Keywords: Asia, atopic dermatitis, attitudes, knowledge, practices


How to cite this article:
Ee S, Tay YK, Chu CY, Hon KLE, Leong KF, Wananukul S. A study on the knowledge, attitudes, and practices of Asian dermatologists in the management of atopic dermatitis. Dermatol Sin 2020;38:67-80

How to cite this URL:
Ee S, Tay YK, Chu CY, Hon KLE, Leong KF, Wananukul S. A study on the knowledge, attitudes, and practices of Asian dermatologists in the management of atopic dermatitis. Dermatol Sin [serial online] 2020 [cited 2020 Sep 25];38:67-80. Available from: http://www.dermsinica.org/text.asp?2020/38/2/67/285351




  Introduction Top


Atopic dermatitis (AD) is a chronic and pruritic inflammatory skin disorder that occurs worldwide. It is a disease that involves complex interactions among susceptible genes, skin barrier defects, environmental factors, immunological factors, infections, and neuroendocrine factors.[1] The overall prevalence of AD is increasing, affecting now not only developed countries but also developing countries.[2],[3],[4],[5] This can pose a significant burden on healthcare resources and patients' quality of life.

Several guidelines on the management of AD have been published in the literature.[6],[7],[8],[9],[10] There was a previous study, comparing the management of this disease by dermatologists in Southeast (SE) Asian countries, namely Singapore, Malaysia, Indonesia, the Philippines, Vietnam, and Thailand.[11]

The survey demonstrated wide regional variability in attitudes and practice among the studied cities. This study aims to survey whether there are changes to the practice in the management of AD in SE Asia 10 years later. A questionnaire survey was sent to dermatologists in Singapore, Malaysia, Thailand, Taiwan, and Hong Kong to evaluate the knowledge, attitudes, and practice in the management of AD.


  Materials and Methods Top


A questionnaire survey of dermatologists belonging to the Dermatological Societies of Singapore, Malaysia, Thailand, Taiwan, and Hong Kong was carried out in 2018. In each country, a standardized questionnaire [Appendix 1] was sent to dermatologists belonging to the respective Dermatological Society. To simplify the questionnaire and protect the confidentiality of the respondents, we decided not to include the demographic data of the respondents. The questionnaire forms were then returned to the respective Dermatological Societies for data collation. Statistical analysis was performed using the SPSS Statistics for Windows, version 24.0 (SPSS Inc., Chicago, Ill., USA). Descriptive statistics will be presented using percentages and 95% confidence intervals, where appropriate. Pairwise comparisons between two countries on each item of the questionnaire will be assessed using Chi-square test or Fisher's exact test. Statistical significance was set at P < 0.05. IRB approval was waived as the study used an anonymous questionnaire and no personal data was collected the respondents.

Epidemiology

The results of the questionnaire can be seen from [Table 1]. A total of 118 dermatologists participated in the study. Most dermatologists were familiar with the diagnostic criteria of Hanifin and Rajka. All the respondents (100%) in Malaysia were familiar with this criterion. The following proportion of respondents who were familiar with the diagnostic criteria of Hanifin and Rajka were: Singapore (80%), Thailand (92%), Taiwan (84.6%), and Hong Kong (55.6%). Most of the respondents from Singapore (76%) and Malaysia (75%) were also familiar with the UK Working Party's diagnostic criteria, but this was not seen among respondents from Thailand (12%), Taiwan (33.3%), and Hong Kong (33.3%).
Table 1: Results of questionnaire survey

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The proportion of patients suffering from AD seen by the respondents varied considerably among the five countries. About 44% of the Singapore respondents felt that 25%–50% of their patients had AD, which is similar to what was seen from Thailand (48%). About 50% of the Malaysian respondents reported that at least 50% of their patients have AD. Majority of the respondents from Taiwan (76.9%) and Hong Kong (55.5%) felt that <25% of their patients had AD.

Clinical presentation

The majority of patients who presented to the respondents had moderate AD. The percentages for the five countries are as follows: Singapore (92%), Malaysia (85%), Thailand (88%), Taiwan (87.2%), and Hong Kong (100%).

About 30.8% of respondents from Taiwan and 44.4% of respondents from Hong Kong saw most of their patients presenting with severe AD, which is significantly higher than respondents in Singapore (12%), Malaysia (5%), and Thailand (4%) (P < 0.05).

The proportion of patients presenting with mild disease in Singapore and Thailand are both at 48%. This is significantly higher than Malaysia (15%), Taiwan (20.5%), and Hong Kong (0%) (P < 0.05).

Trigger factors

The respondents thought that the following were the most common triggering or aggravating factors for AD in their country, in descending order of frequency: Singapore (stress, sweating from excessive heat, skin infection), Malaysia (excessive heat sweating, skin infection, dusty environment), Thailand (stress, sweating from excessive heat, climate change), Taiwan (climate change, sweating from excessive heat, skin infection), and Hong Kong (stress, skin infection, climate change).

Most respondents felt that <25% of their AD patients had food allergy as a trigger. Some respondents in Singapore (12%), Thailand (12%), Malaysia (5%), and Taiwan (10.3%) thought that food allergy was a trigger in >25% of their AD patients. All respondents from Hong Kong felt that <10% of their AD patients had food allergy as a trigger. Most respondents investigated for food allergy or aeroallergen hypersensitivity in AD.

Responses regarding patch testing in the management of AD were varied. Majority of the respondents in Singapore (56%) carried out patch testing infrequently and 36% of them do so sometimes. 55% of the Malaysian respondents do patch testing sometimes and 35% of them do so infrequently. 56% of the respondents from Thailand do patch testing infrequently and 32% of them do not perform patch testing in AD at all. Most of the respondents from Taiwan (48.7%) do not perform patch testing and 41% of them perform patch testing infrequently. 44.4% of the respondents from Hong Kong do not perform patch testing, 33.3% of them perform patch testing infrequently and 22.2% of them perform patch testing sometimes.

Management

Most of the respondents from Singapore (92%) and all respondents from Malaysia and Thailand always used moisturizers for the acute phase of treatment. 61.5% of the respondents from Taiwan and 66.7% of the respondents from Hong Kong used moisturizers in the acute phase of treatment, while 25.4% of the respondents from Taiwan and 11.1% of the respondents from Hong Kong do so sometimes. The proportion of respondents from Taiwan and Hong Kong who always use moisturizers in the acute phase is significantly less compared to the other three countries (P < 0.05).

All respondents from Singapore, Malaysia, Thailand, and Hong Kong always used moisturizers in the maintenance phase of treatment. 97.4% of respondents from Taiwan always used moisturizers in the maintenance phase of treatment, while 2.6% of them do so sometimes.

Most of the respondents from Singapore (72%), Thailand (76%), Malaysia (95%) and Hong Kong (66.7%) use newer specific emollients containing ceramides or natural moisturizing factors (NMF) sometimes. 46.2% of the respondents from Taiwan would always use these newer emollients and the same proportion (46.2%) would use these sometimes. This difference in proportion among countries is not statistically significant (P > 0.05).

The large majority of respondents from all countries (83.3%–100%) used topical corticosteroids in infants with AD when the disease was moderate or severe. More than half of the respondents from Singapore (52%), Thailand (60%), and Malaysia (65%) used topical corticosteroids in infants with mild AD. However, the proportion of respondents from Taiwan and Hong Kong who used topical corticosteroids in infants with mild AD was less at 38.5% and 33.3%, respectively.

Most of the respondents from all countries (77.8%–95%) would use topical corticosteroids in children with severe AD. It was observed that only 48% of respondents from Thailand would do so in children with moderate AD, whereas 77.8%–100% of respondents from the remaining three countries would continue to prescribe topical corticosteroids in children with moderate AD. In children with mild AD, the proportion of respondents who would use topical corticosteroids are: Singapore (88%), Malaysia (90%), Thailand (60%), Taiwan (64.1%), and Hong Kong (55.6%).

The potency of topical corticosteroids that are most frequently used in infants and children with AD are mild and moderate. None of the respondents used high or super potency topical corticosteroids in infants or children with AD.

A large majority of the respondents from Singapore, Malaysia, Thailand, and Taiwan used topical calcineurin inhibitors in AD (95% to 100%). Although most of the respondents from Hong Kong (55.6%), used topical calcineurin inhibitors in AD, this proportion is significantly lower as compared to the other four countries (P < 0.05). One respondent from Malaysia and one respondent from Hong Kong indicated that topical calcineurin inhibitor was not available in their practice.

With regard to steroid phobia, most of the respondents from Singapore (64%), Malaysia (55%) and Taiwan (41%) felt that 25%–50% of their patients have steroid phobia. 64% of the respondents from Thailand felt that <25% of their patients have steroid phobia. 33.3% of respondents from Hong Kong felt that >75% of their patients have steroid phobia.

Most of the respondents (84%–95%) from the five countries would prescribe systemic antibiotics for patients with severe infected eczema. 33.3% of respondents from Hong Kong would prescribe systemic antibiotics in patients with moderately infected eczema and this was significantly lower when compared with the remaining 4 countries (P < 0.05). A small proportion of respondents in Singapore (12%), Thailand (8%), Malaysia (5%), and Hong Kong (11.1%) would do so when the infection was mild.

About 96% to 100% of respondents from Thailand would use topical mupirocin and/or fusidic acid, 13% of them would use a combination of steroids and antibiotics. These options were also frequently used by respondents from Malaysia and Hong Kong. Among the respondents from Malaysia, 95% used fusidic acid, 70% used a combination of corticosteroid and antibiotics, and 30% used mupirocin. Topical fusidic acid and a combination of steroids and antibiotics are also commonly used by respondents from Hong Kong at 77.8% and 55.6%, respectively. 22.2% of respondents from Hong Kong used topical mupirocin.

The responses from the dermatologists in Taiwan were more varied with regard to the medications used, in descending order are: fusidic acid (84.6%), combination of corticosteroid and antibiotics (53.8%), tetracycline (25.6%), polymycin, bacitracin and neomycin combination (23.1%), and mupirocin (20.5%).

Mupirocin and tetracycline are the most commonly used agents among respondents from Singapore, at 72% and 52%, respectively. 48% of them use fusidic acid and 13% of them used a combination of corticosteroid and antibiotics.

The top three systemic antibiotics that were prescribed most frequently by respondents were, in descending order of frequency: cephalosporin, for example, cephalexin, cloxacillin, and amoxicillin/clavulanic acid combination.

In Taiwan and Hong Kong, respectively, 23.1% and 22.2% of the respondents prescribed amoxicillin most frequently; this proportion was not significantly greater than the other countries (P > 0.05). Four precent of the respondents from Thailand prescribed amoxicillin/clavulanic acid which is significantly less compared to other countries (P < 0.05).

Most of the respondents often or sometimes prescribe antihistamines. Majority of respondents from Singapore, Malaysia, Thailand, and Taiwan use both sedating and nonsedating antihistamines: Singapore (88%), Malaysia (85%), Thailand (52%), and Taiwan (87.2%). In contrast, 11.1% of respondents from Hong Kong used both sedating and nonsedating antihistamines (P < 0.05). The dermatologists from Singapore (88%) and Thailand (52%) often use both nonsedating and sedating antihistamines together. About 66.7% of respondents from Hong Kong, 48% of respondents from Thailand, and 12% of respondents from Singapore use only sedating antihistamines. There are some respondents from Malaysia (15%) and Thailand (12.5%) who use only nonsedating antihistamines.

Phototherapy, systemic therapy, wet wrap therapy, complementary and alternative medicine

All respondents from Singapore use phototherapy, followed by 92.3% of respondents from Taiwan, 90% of respondents from Malaysia. Only 24% of respondents from Thailand and 33.3% of respondents from Hong Kong would use phototherapy for their AD patients, which is significantly lower compared to the other countries (P < 0.05).

Among respondents who use phototherapy as part of AD treatment, the most frequently used modality is narrow band ultraviolet (UV)-B. It is used by 100% of respondents from Singapore, Malaysia, and Hong Kong, 89.7% of respondents from Taiwan and 81.25% of respondents from Thailand. Other modalities such as UVAB, UVAI, and psoralen plus UV A (PUVA) are not commonly used by respondents from all countries (0%–15.4%). Some respondents from Thailand (36%) and Hong Kong (11.1%) did not answer the question.

In patients with severe AD, most respondents from Singapore use oral steroids (96%), cyclosporin (92%), azathioprine (80%), and methotrexate (72%). All respondents from Malaysia use azathioprine, 90% use oral steroids, 75% use methotrexate and 70% use cyclosporin. Among the respondents from Thailand, oral steroids (64%), and cyclosporine (44%) are most commonly used. None of them use azathioprine and the proportion of respondents using methotrexate and mycophenolate are at 8% each. 97.4% of Taiwan respondents use oral steroids in severe AD. The respondents from Taiwan also used azathioprine (59%), cyclosporin (59%), and methotrexate (25.6%). Most of the respondents from Hong Kong used systemic steroids (66.7%) and azathioprine (66.7%). Fewer respondents from Hong Kong used cyclosporin (22.2%) and methotrexate (22.2%).

Mycophenolate mofetil is uncommonly used among all the respondents. The proportion of respondents who used mycophenolate mofetil are: Singapore (32%), Hong Kong (22.2%), Thailand (8%), Taiwan (7.7%), and Malaysia (0%).

Wet wrap therapy is used sometimes and infrequently (44.4%–88%) by respondents from all countries. A few respondents from Malaysia (10%) and Taiwan (5.1%) always use wet wraps as part of treatment of AD. About 44.4% of respondents from Hong Kong do not use wet wraps for their AD patients.

Almost all of the respondents do not recommend the use of complementary and alternative medicine (CAM) for the treatment of AD. The few respondents who recommend the use of CAM are from Singapore (4%), Thailand (4%), Taiwan (10.3%), and Hong Kong (22.2%).

Patient education

Responses with regard to eczema action plans were varied. Most of the respondents from Singapore (52%) provide eczema action plans sometimes and 36% of them do so infrequently. Only 12% of the respondents from Singapore always use eczema action plans. A greater proportion (36%) of respondents from Thailand always use eczema action plans; though, it is observed that 20% of them do not use eczema action plans at all. 85% of the respondents from Malaysia always or sometimes use eczema action plans. Most of the respondents (38.5%) from Taiwan do not use eczema action plans. 15.4% of these respondents always use eczema action plans, 35.9% sometimes use and 10.3% infrequently do so. Most of the respondents from Hong Kong (55.6%) infrequently use eczema action plans, 33.3% of them sometimes provide eczema action plans and 11.1% always do so.

Most of the respondents from Singapore (96%), Taiwan (84.6%), Malaysia (80%), and Thailand (57%) always or sometimes provide information leaflets on AD. About 44.4% of respondents from Hong Kong always or sometimes provide such leaflets to aid in patient education. A small minority of respondents from Singapore (4%), Malaysia (5%), and Taiwan (7.7%) do not provide patients with leaflets on AD. The proportion of dermatologists who do not provide leaflets is higher among respondents from Thailand (20%) and Hong Kong (44.4%). Comparing the proportion of respondents who do not provide leaflets in Hong Kong with Singapore, Malaysia, and Taiwan, a statistical significance is seen (P < 0.05). However, the statistical significance is not seen when the proportion of respondents from Thailand who do not provide information leaflets is compared with Singapore, Malaysia, and Taiwan (P > 0.05).


  Discussion Top


The sample size of respondents was small, which meant that these findings may not reflect the management trends in these countries. The respondents from Thailand were all pediatric dermatologists, whereas the respondents from the other three countries were both adult and pediatric dermatologists. All the respondents from Hong Kong were adult dermatologists which can be a reason why AD is not often seen. About half of the respondents from Singapore and Malaysia were from tertiary hospitals and the remainder were from private clinics. More than 90% of respondents from Taiwan and all respondents from Thailand were from tertiary hospitals. All respondents from Hong Kong were from private clinics.

Most of the respondents were familiar with the diagnostic criteria of Hanifin and Rajka. Only a small proportion of respondents from Thailand and Taiwan were familiar with the UK Working Party's diagnostic criteria. Both the Hanifin and Rajka and UK Working Party diagnostic criteria have been validated in studies and tested in several different populations.[12]

Diagnostic criteria become particularly important when different populations are compared in epidemiological studies and clinical trials. Familiarity with two commonly used diagnostic criteria varies considerably among dermatologists of the five different countries and this fact must be taken into consideration when studies on AD are done in SE Asia.

Patients with AD accounted for a large proportion of the patients seen by the majority of the dermatologists. The majority of patients who presented to the respondents had mild-to-moderately severe AD on the first presentation. This has several possible reasons: (a) patients may be able to easily access specialist medical care and presented in early phase of disease; (b) primary care physicians may not have been comfortable with the management of AD and were referring even mild cases to the dermatologists; (c) patients may have preferred to be under the care of dermatologists; and (d) most primary care physicians do not use any objective/subjective severity or quality of life scores to evaluate their patients.

More than 60% of the dermatologists from all countries thought that <10% of their AD patients had food allergy as a trigger. However, majority of them sometimes investigated for food allergy. Notably, 44% of the respondents from Singapore do so even though only 12% of them felt >25% of their patients had food allergy as a possible trigger. Possible reasons for such a disparity may be due to increasing requests from patients to perform food allergy testing and food allergy testing being widely available. It is important to be cautious while interpreting skin prick tests or specific IgE tests for food allergies in view of the high rates of false positivity.[13] Physician and patient misinterpretation of the relevance and reliability of allergy testing may lead to misdirected interventions.

Moisturizers are useful in prevention and maintenance therapy. They have been shown to improve skin barrier function and symptoms severity.[14],[15] Proper moisturizer therapy can reduce the frequency and intensity of flares, reducing the need for topical anti-inflammatory therapy. There was a significantly lower proportion of Taiwan and Hong Kong respondents prescribing moisturizers in the acute phase of AD. Moisturizers should still be used in conjunction with topical corticosteroids or calcineurin inhibitors in the acute phase of AD.

Recent advances in the understanding of the pathophysiological process of AD involving filaggrin and ceramides has led to the production of novel moisturizers containing natural moisturizing factors and ceramides. Some studies have shown that these products reduce trans-epidermal water loss with better skin hydration and clinical scores.[16],[17] From our results, most respondents always or sometimes recommend ceramide or NMF-containing emollients. These newer emollients are more expensive, which can explain why they are less frequently prescribed. A recent systematic review has shown that there is also no evidence that these newer emollients are superior to other moisturizers.[18]

Topical corticosteroids remain the mainstay of therapy for AD. Potential local adverse effects include skin atrophy, telangiectasia, and striae. Topical corticosteroids can also lead to adrenal suppression if there is application to large surface areas over prolonged durations, use of potent topical corticosteroids to flexural areas. All these side effects are associated with inadvertent usage. It was observed that most respondents from Thailand felt that <25% of their patients were steroid-phobic. These respondents attribute this low percentage to physician education on effective and appropriate use of topical corticosteroids.

Most respondents use topical corticosteroids in infants when AD is moderate to severe. More than half of the respondents from Singapore, Malaysia and Thailand use topical corticosteroid in mild disease, compared to 38.5% of the respondents from Taiwan and 33.3% of the respondents from Hong Kong. In children with AD, most of the respondents would prescribe topical corticosteroid in mild, moderate or severe disease. The types of topical corticosteroid used are of mild or moderate potency. None of the respondents used potent or super potent corticosteroids, a possible reason is to minimize the risk of suppression of the hypothalamus-pituitary-adrenal axis and the risk of cutaneous atrophy.

The topical calcineurin inhibitors, tacrolimus and pimecrolimus, have been shown to reduce the severity of AD in adults and children. They have a good short and medium-term safety record with the lack of corticosteroid-associated side effects like striae, atrophy and pituitary-adrenal suppression. Only two respondents indicated that topical calcineurin inhibitors were not available in their practice, while the remaining respondents do prescribe them. From the previous study, 88% of respondents from Malaysia have not used topical calcineurin inhibitors and 45% of them also indicated that these medications were not available in their practice.[11] This may signify that topical calcineurin inhibitors are now more widely available in Malaysia.

Patients with AD can develop secondary infections with a variety of microbial organisms, including Staphylococcus, Streptococcus and herpes simplex. Infection with Staphylococcus aureus is the most common complication of AD. Bacterial colonization is well recognized as an important exacerbation factor that can promote acute AD flares.[19],[20]

It is estimated that patients with AD carry S. aureus in 90% of clinically affected areas and 75% of uninvolved areas.[21] A study performed in a tertiary center in Singapore reported that S. aureus was isolated in 53% of patients with mild dermatitis and 100% of those with moderate to severe dermatitis.[22] Approximately 30% of the general population are also carriers, and hence, skin swabs from AD patients may not be helpful in differentiating colonization from infection.[21] Infected AD requires treatment with antimicrobials and topical antimicrobials can be used in localized infected AD.

Flucloxacillin (dicloxacillin) is normally active against both staphylococcus and streptococcus and is considered to be the first-line therapy infected AD. Amoxicillin is not recommended in view of increasing resistance of S. aureus to amoxicillin. None of the respondents from Singapore prescribed amoxicillin but small proportions of respondents from the remaining countries still do. Physicians should also be aware of local patterns of antimicrobial resistance and tailor their prescription accordingly.

There is no high-level evidence to suggest that non-sedating antihistamines reduce itch in AD.[23] Sedating antihistamines may provide benefit in patients with affected sleep secondary to itch. From the survey results, it is observed that 12% of respondents from Singapore, 48% of respondents from Thailand, and 66.7% of respondents from Hong Kong prescribed only sedating antihistamines. Majority of the respondents prescribed non-sedating antihistamines as part of their management of AD.

Wet wrap therapy in the form of damp gauze dressings or double pyjamas method is a relatively safe addition to treating patients with moderate to severe AD.[24] These dressings occlude the affected area, leading to enhanced absorption of topical corticosteroids and reduced access to scratching.

In a systematic review done by Devillers and Oranje,[25] ten small-scale studies of wet-wrap treatment in children with moderate-to-severe AD were reported. All of the studies showed improvement in eczema severity, though the type of dressings, emollients, and topical steroids used were different. From our survey, most of the respondents do not use wet wraps therapy frequently. One possible reason is because this mode of treatment is rather labor-intensive, it may not be well-received by many patients and thus only be done in patients who are highly motivated. Furthermore, there is a popular Asian belief that a cold and damp environment can lead to rheumatism, which may lead to a low rate of wet wrap therapy being used by Asian patients.

Phototherapy is a well-established treatment modality for severe AD in both adults and children. Phototherapy comprises broadband, narrowband, photochemotherapy PUVA, and UV-A1. Narrowband UV-B and UV-A1 are the most frequently used regimens in AD patients.[26] From the results, all respondents from Singapore and majority of the respondents from Malaysia and Taiwan use phototherapy. This is different from the previous study done in 2006 where most of the respondents who used phototherapy came from Singapore.[11] This may represent an increased availability of phototherapy services in Malaysia and Taiwan.

Systemic agents are generally reserved for persistent, widespread and non-responsive AD that is unresponsive to topicals and phototherapy. Systemic corticosteroids are the most widely used systemic agent by respondents from all countries.

Cyclosporin is recommended as a first-line option in AD refractory to conventional treatment.[27] Randomized controlled trials in both adults and children have confirmed that cyclosporin is effective in the short-term management of severe AD, at doses of 3–5 mg/kg per day. However, treatment is limited by short-term side effects such as nausea and paraesthesia, and long-term side effects such as renal impairment, hypertension and cutaneous changes such as gingivitis and hypertrichosis. Mycophenolate mofetil has been reported to be useful in adults with severe AD[28] and those with widespread refractory AD.[29] Both methotrexate and azathioprine have demonstrated improvements in severe AD, and are relatively well tolerated in the short term.[30]

There is a difference in the choice of systemic immunosuppressants among the respondents. Majority of the respondents from Singapore and Malaysia prescribe cyclosporin while lower proportions are seen in the remaining three countries. In Singapore and Malaysia, patients bear the full cost of their medications. National health insurance is present in Taiwan and Thailand, but this scheme does not fully cover the costs of extensive systemic therapy. These differences in health insurance systems may affect treatment decisions.

CAM is widely available in Asian countries. Although effective conventional therapies exist, the nature of the disease, with remissions and relapses, its chronicity and the fear of long-term steroid use, encourages patients to seek out CAM which they perceive to be safe. However, efficacy has not been consistently demonstrated. Meta-analyses performed by Cochrane reviewers showed no convincing evidence that oral intake of most Chinese herbs or Chinese herbal formulae used could improve AD.[31] Cochrane reviews have demonstrated no definite evidence of the efficacy of other alternative therapies.[32] In many Asian countries, many patients try both CAM and Western medicine.

Patient education has been shown to help improve adherence, prevent complications, and improve quality of life of chronic diseases.[33] Patient education using both eczema action plans and providing information leaflets are not frequently carried out by the respondents. An eczema action plan is an individualized tool to help caregivers and patients self-manage eczema. Potential benefits of an eczema action plan include allowing patients and carers to be more confident in managing skin symptoms, which can, in turn, improve adherence to treatment. This is an area that would need improvement as patient education can enhance continuity of care and reduce AD-related complications.


  Conclusion Top


Compared to the previous study, there is an improvement in the proportion of dermatologists in SE Asia using topical calcineurin inhibitors and phototherapy.[5] This may signify better access to these treatment modalities throughout the region. There are certain aspects of management that can still be improved, such as the use of moisturizers in the acute phase of AD, wet wrap therapy and patient education. Certain factors such as cost issues, steroid phobia, and personal motivation may explain why these aspects of AD treatment are still not widely practised. Educational programs that allow a patient-centered approach should be recommended as an adjunct to medical therapies. Overall, the management of AD among Asians requires a holistic approach, while considering accessibility and cultural differences.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.


  Appendix 1: Questionnaire Form Top


  1. Are you familiar with the following diagnostic criteria for atopic dermatitis? (You may circle more than 1.)


    1. UK working party's diagnostic criteria of Williams HC et al
    2. Diagnostic criteria of Hanifin and Rajka
    3. American Academy of Dermatology diagnostic criteria


    1. What percentage of your patients do you think suffers from atopic dermatitis (AD)?
    2. < 25%
    3. 25-50%
    4. > 50%


  2. What percentage of your patients with AD are children (<16 years old)


    1. < 25%
    2. 25-50%
    3. > 50%


  3. For majority of your AD patients, how severe is their disease at first presentation? (You may circle more than 1.)


    1. Mild
    2. Moderate
    3. Severe


  4. What usually triggers/aggravates your patients' condition? (You may circle more than 1.)


    1. Food allergy
    2. Stress
    3. URTI
    4. Skin infection
    5. Climate change
    6. Excessive heat sweating
    7. Dusty environment
    8. Contact with sand, grass
    9. Others


  5. What proportion of your AD patients are presumed to have food allergy as a trigger of their condition?


    1. < 10%
    2. 10-24%
    3. 25-50%
    4. > 50%


  6. How often do you investigation for food allergy or aeroallergen hypersensitivity in the management of AD?


    1. Always
    2. Sometimes
    3. Infrequent
    4. Never


  7. How often do you do patch testing in the management of AD?


    1. Always
    2. Sometimes
    3. Infrequent
    4. Never


  8. How often do you recommend moisturisers for the clear acute phase of treatment?


    1. Always
    2. Sometimes
    3. Infrequent
    4. Never


  9. How often do you recommend moisturisers for the maintenance phase of treatment?


    1. Always
    2. Sometimes
    3. Infrequent
    4. Never


  10. How often do you use the newer specific emollients (Ceramide, natural moisturising factor containing)?


    1. Always
    2. Sometimes
    3. Infrequent
    4. Never


  11. How often do you recommend the use of soap-less cleansers?


    1. Always
    2. Sometimes
    3. Infrequent
    4. Never


  12. How often do you recommend the use of bleach baths for infected eczema?


    1. Always
    2. Sometimes
    3. Infrequent
    4. Never


  13. When do you use topical corticosteroids in infants with AD? (You may circle more than 1.)


    1. Mild disease
    2. Moderate disease
    3. Severe disease


  14. When do you use topical corticosteroids in children (< 16 years old) with AD? (You may circle more than 1.)


    1. Mild disease
    2. Moderate disease
    3. Severe disease


  15. What potency of topical corticosteroids do you most frequently in infants and children? (You may circle more than 1.)


    1. Mild potency
    2. Moderate potency
    3. High potency
    4. Superpotent


  16. What percentage of your patients have corticosteroid fear or concerns?


    1. < 25%
    2. 25 – 50%
    3. 50 – 75%
    4. > 75%


  17. Have you prescribed the topical calcineurin inhibitors (pimecrolimus and/or tacrolimus)?


    1. Yes
    2. No
    3. Not available


  18. How often do you recommend the use of pro-active topical corticosteroid therapy?


    1. Always
    2. Sometimes
    3. Infrequent
    4. Never


  19. How often do you recommend the use of pro-active topical calcineurin inhibitor therapy?


    1. Always
    2. Sometimes
    3. Infrequent
    4. Never


  20. For infected eczema, when do you prescribe systemic antibiotics? (You may circle more than 1.)


    1. Mild infection
    2. Moderation infection
    3. Severe infection


  21. Which of the following antibiotics do you prescribe most frequently for AD patients? (You may circle more than 1.)


    1. Tetracycline
    2. Mupirocin
    3. Fusidic acid
    4. Polymycin, bacitracin and neomycin combination
    5. Combination of corticosteroid and antibiotic
    6. Others, please specify: ____________________


  22. Which of the following systemic antibiotics do you prescribe most frequently for AD patients? (You may circle more than 1.)


    1. Amoxicillin
    2. Cloxacillin or dicloxacillin or oxacillin
    3. Erythromycin
    4. Cephalosporins
    5. Cotrimoxazole
    6. Others please specify: _____________________


  23. How often do you prescribe oral antihistamines for your patients with AD?


    1. Always
    2. Often
    3. Sometimes
    4. Infrequent
    5. Never


  24. Types of oral antihistamines prescribed


    1. Sedating type only
    2. Non-sedating type only
    3. Both, sedating and non-sedating
    4. Not applicable (if your answer to Q24 is e)


  25. Which of the following do you use in severe AD? (You may circle more than 1.)


    1. Oral steroids
    2. Cyclosporine
    3. Azathioprine
    4. Methotrexate
    5. Mycophenolate mofetil
    6. Others, please specify: ________


  26. How often do you use wet wraps therapy in the management of AD?


    1. Always
    2. Sometimes
    3. Infrequent
    4. Never


  27. Do you use phototherapy for your AD patients?


    1. Yes
    2. No


  28. If you use phototherapy for your AD patients, please specify the type of phototherapy. (You may circle more than 1.)


    1. Broad band UVB
    2. Narrow band UVB
    3. UVAB
    4. UVAI
    5. PUVA


  29. Do you recommend the use of complementary and alternative medicines such as traditional Chinese medicines and homeopathy?


    1. Yes
    2. No


  30. Do you use eczema action plans?


    1. Always
    2. Sometimes
    3. Infrequent
    4. Never


  31. Do you provide patient information leaflets on atopic dermatitis?


    1. Always
    2. Sometimes
    3. Infrequent
    4. Never




 
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