Atopic dermatitis (AD) is a chronic inflammatory disease of immunologic origin, characterized by the presence of pruritus and eczema, and with a range of manifestations depending on the age of the patient and other factors.1–3 It is estimated that AD is one of the most common skin diseases, associated with a high socioeconomic cost.4 Between 20% and 25% of children are affected,1 in particular babies. In adults, as many as 17% may have the condition,5 with a third of cases being moderate to severe in intensity.6

The pathophysiology of AD includes deregulation of the immune system and compromised skin barrier,2 leading to a large number of atopic and nonatopic comorbidities.7 Overall, these have a major negative impact on the quality of life of patients with this disease4 and there is a clear association with anxiety and depression.8,9

Despite recent advances in therapeutics for AD, efficient control of moderate/severe disease is still challenging. In addition to the appropriate use of the pharmacological treatments available, collaboration between specialties could be a beneficial factor for improving the health and quality of life of patients, as well as for increasing the effectiveness of treatment, so contributing to the sustainability of the health system. From the perspective of an increasingly restrictive pharmacoeconomic setting, the only way to ensure that innovative and expensive drugs can be used is to apply consensus protocols and pharmacotherapeutic guidelines drawn up not only by the corresponding clinical specialty, in this case dermatology, but also by the hospital pharmacy.

In view of the above, and given that many of the treatments indicated for moderate/severe AD are dispensed by the hospital pharmacy, a collaboration between dermatology and hospital pharmacy would seem appropriate. In order to address this aspect, in this article, the vision of dermatologists and hospital pharmacists has been shared, with the following objectives: assessment of the current situation, identification of points of conflict in management of AD, definition of working strategies, and proposal of recommendations for action in different situations.

The 51 experts responded to two rounds of the Delphi questionnaire, using a numerical Likert scale; in addition, comments were permitted for each response.

The 73 assertions defined by the scientific committee were submitted to the first round for consensus. The expert panel reached an initial consensus in 57 (78%) of the 73 assertions. The 16 assertions for which consensus was not reached were submitted to a second round, reaching agreement in 6 (38% consensus in the second round). The total number of assertions with consensus, taking into account both rounds, was 63, so the final percentage agreement was 86%. There was no disagreement in any of the assertions.

Moderate/severe AD still requires a complex approach, due to the multifaceted nature of the disease.4,7–9,12–14 An initial evaluation should be performed of the scope and severity of the disease in order to select the most suitable therapy.9

In addition to the conventional systemic treatments recommended by the European guidelines,15 new therapeutic families have recently become available (biologics and synthetic molecules). Through the use of these new agents, the goal is to regulate or inhibit the activity of different cell mediators implicated in the inflammatory pathways that underlie AD manifestations.3,16,17 Several biologics have been approved and many others are in development or can be used off-label in AD. We are still awaiting consensus guidelines to define the therapeutic steps with biologics. With regards the recommendations for systemic immunosuppressants, there is disagreement as to whether these should be administered to patients with moderate/severe AD (SCORAD>25); the experts noted that other variables should be taken into account such as the site of the lesions, the lack of response to other treatments, contraindications, and also quality of life. Moreover, although there is agreement that patients with severe forms (SCORAD>50) should be candidates for receiving these agents, as well as those with unsatisfactory response to topical treatments, it is of note that an algorithm has yet to be defined in the guidelines that indicates best time to start these agents. Nevertheless, the experts do recommend taking into account comorbidities and patient preference when choosing one treatment or another. We have used the SCORAD scale as we consider it the most complete scale that offers the evaluation best adapted to the clinical situation of the patient, even though the EASI scale is the most widely used in clinical trials.

With regards topical corticosteroids and calcineurin inhibitor use in all patients, discrepancies were identified in the following: (1) the mildest forms, as the experts were of the opinion that these agents may not be necessary, with nonpharmacologic options being sufficient15 and (2) with the most severe forms, as they may not be sufficient from the outset. There was also a discrepancy for accepting NB-UVB phototherapy as a prior step to systemic therapy; the need to attend the hospital several days is a major limitation.

The interpretation whether the therapeutic goal has been achieved is a crucial question, which involves assessing several factors (clinical, patient satisfaction, safety, convenience) and for which there is still no consensus in Spain. The responses reported in this study record the opinion of each participant, based on their own experience.

An important aspect to consider in the assessment of treatment and one which the experts recommend to include in plans for patient follow-up are patient reported outcomes (PROs), in agreement with Cohen et al.,18 whose report identified them as an essential item. The complexity of management of patients with AD often means that the outcomes are not to their satisfaction. PROs complement the outcomes, thus improving case management.19

The experts recommend that follow-up of patients is shared between dermatology and hospital pharmacy, and they propose a multidisciplinary approach when AD is accompanied by other manifestations, both in adults and in children,20 as recommended by the technical report issued by Fundamed.9 In contrast, no consensus was reached on whether therapeutic goals should be defined jointly; some authors think that this should be the remit of the dermatologist with the pharmacists supporting the decisions made by the clinician. Analyzing the scores with the Delphi method, a wide range of responses was observed: there were similar numbers of votes in the ranges 1–3, 4–6, and 7–9. The discrepancy on this point is based on the idea that responsibility for diagnosis, choice of therapeutic goals, and choice of pharmacologic treatment correspond to the dermatologist. The pharmacist participates in this process as a collaborative figure, key for improving aspects of therapeutic compliance and safety, and reinforcing the suitability of the prescription. In this vision, the authors in disagreement do not consider necessary a joint assessment of the patient by the two specialties, as this does not add any clinical benefit. The design of a combined follow-up, based on alternative consultations between the two specialties, could add value to the process, as it would avoid unnecessary appointments for well-controlled patients (for example, spreading out the appointments), at the same time as ensuring compliance and detection of any potential safety issues.

Another point of contention was the possibility that dermatologist and hospital pharmacist see the patients together to facilitate the indication of certain treatments. The experts note that while this would be the ideal situation to know the patients better, it is not realistic; they propose alternatives such as interdisciplinary sessions, or that the hospital pharmacist rotates with dermatology.

To favor therapeutic compliance, the experts agree that there should be a good relationship between the patient and physician. They therefore recommend improving patient access to the dermatologist as also noted by Cohen et al.18 In this context, the remote care models will become increasingly important.21 With regards the greater patient access to the hospital pharmacist, there is a greater trend to agreement, but there is more variability than in other questions and there was no consensus reached. This could be the result of large differences in organization and resources in Spanish hospitals, such that the need for access is perceived according to the particular situation of the respondent. It is not unexpected that there was no consensus on this question, as the specific dedication of a pharmacist to patients with AD is not usual in many hospitals, understandably for reasons related to care requiring diversification to several specialties. This is a model that could be considered in most of the centers, with doubts about the potential benefits (basically, the dermatologists question the need for this ‘superspecialization’) on the one hand and the risks (greater work load and care pressure, delays in care, etc.) on the other. As a result, there are no comparative data to support one model or the other, and the range of opinions explains the lack of consensus. As an intermediate scenario and with greater practical applications, most hospital pharmacy departments opt for assigning tasks associated with dermatology to a stable part of their personnel (1 or 2 pharmacists), who thus acquire deeper knowledge of both the specialty and the local needs of each department and their patients.

With a view to facilitating therapeutic compliance, education of the patient and their carers is essential. They may be worried about the side effects of topical corticosteroids, have difficulty applying treatments, doubt their effectiveness, and need to be aware of other nonpharmacological measures to improve their quality of life.22–24 The experts were not in agreement as to who should be responsible for this task of education. Several noted that it would be the responsibility of both the dermatologist and hospital pharmacist, with support from nursing, as indicated in the guidelines,15 primary care, and community pharmacists, always aiming to transmit a uniform and agreed message.

In conclusion, at present, a series of challenges remain in the management of care of moderate/severe AD.18,25 The experts propose starting from an interdisciplinary approach to AD and improving communication and collaboration between dermatology and hospital pharmacy, with the aim of finding faster, more suitable, and more efficient solutions for patients and thus improving management of the disease.

This research project was financed by Lilly S.A.

The authors declare that they have no conflicts of interest.