Access to Emollients in Atopic Dermatitis

Abstract

In addition to symptoms, the management of atopic dermatitis (AD) can significantly impact quality of life. Chronic disease can present a considerable financial burden for patients and families. The cost of treatment can lead to poor adherence and contribute to social inequality in access to care.

Emollients represent a cornerstone of therapy in AD. Van Zuuren et al.'s [1] Cochrane review established that moisturisers reduced the number of flares, prolonged the interval between flares and reduced the need for corticosteroids. In addition, they reported that a combination therapy of moisturisers and topical corticosteroids were more effective than topical corticosteroids alone.

Despite the inclusion of emollients in all clinical guidelines and the frequency of their prescription, few are covered on General Medical Services (GMS) and the Drug Payment Scheme (DPS) in Ireland, presenting financial barriers for many. A search of reimbursable items on the HSE website [2] reveals that Emulsifying ointment, Silcocks base and Aqueous cream—an emollient no longer recommended in AD due to its sodium lauryl sulphate (SLS) content—are reimbursed, whereas paraffin gel, Hydromol, Doublebase cream, Epaderm, CeraVe, E45 and Aveeno are not. Research suggests that individuals with atopic dermatitis should avoid SLS-containing products as it can exacerbate symptoms by disrupting the already compromised skin barrier, leading to irritation and inflammation and increased erythema, pruritis and dryness.

In contrast, commonly prescribed topical steroids such as Dermovate, Betnovate, Dovobet, Elocon and Eumovate are reimbursed. The reason for this discrepancy is unclear. In Ireland, patients can apply for reimbursement of a product not on formulary under the Discretionary Hardship Scheme, however, each application is assessed on a case-by-case basis.

Quantification of the out-of-pocket cost to the patient merits consideration. Patients on lower incomes may struggle to afford emollients, with resultant disparities in access based on socioeconomic status. Qualification for healthcare coverage such as medical cards can also significantly impact access. The Irish Skin Foundation advises that the typical minimum quantity of emollient required by a child with AD is 250 g of ‘leave-on’ emollient per week, while that of an adult is approximately 500 g per week. The cost of a 500 g tub of paraffin gel is 14.65 euros at the time of writing. This equates to 14.65 euros per week or 761.80 euros per year if an adult patient were to adhere to the Irish Skin Foundation advice [3]. Launois et al. [4] found that for patients with AD, the cost associated with emollients is significantly higher in patients with severe AD relative to those with moderate or mild AD.

Studies across Europe suggest that out-of-pocket costs for patients with AD is an issue of international scope. In France, Launois et al. [4] found the total of non-reimbursed expenditures per patient with severe AD amounted to €462.1 annually; emollients were one of the most frequently used resources. Mohr et al. [5] in Germany and Argenziano et al. [6] in Italy also document the non-reimbursement of basic emollients. In a study across nine European countries, Zink et al. [7] reported an average of €927 was spent by every patient every year without reimbursement; emollients and moisturisers accounted for the highest monthly costs.

The high costs of emollients are unlikely to reduce in the years to come and we must ask ourselves how much are patients willing and able to pay to maintain and treat their disease. It is essential that we expand the perimeter of medicaments reimbursed for patients with AD to limit exacerbations of the disease and improve quality of life for patients and families. Given that emollients are vital components of the treatment of atopic dermatitis, their reimbursement status merits reconsideration.

Stephanie Ryan: writing–original draft-lead, writing-review and editing-lead. Cristina Grechin: writing–review and editing-supporting. Richard Watchorn: supervision, writing–review and editing–supporting.

Not applicable.

The authors declare no conflicts of interest.