Topical corticosteroids, a first-line therapy for atopic dermatitis, appear to be poorly prescribed for pediatric patients, based on an analysis of data from two national databases of patient visits.
Fewer than a third of the estimated 7.4 million physician visits for AD by pediatric patients between 1997 and 2004 involved a prescription for topical corticosteroids, reported Dr. Kimberly A. Horii of the dermatology section at Children's Mercy Hospitals and Clinics in Kansas City, Mo., and her colleagues.
"Topical corticosteroids are accepted first-line anti-inflammatory agents to treat flares of AD," the researchers wrote. Surprisingly, fewer than one-third of all pediatric [AD] visits and fewer than one in four visits for AD or patients who were younger than 2 years were treated with topical corticosteroids in this cohort, they noted (Pediatrics 2007;120:e527-e34 [Epub doi:10.1542/peds.20070289]).
From 1997 to 2000, there were 2.8 million outpatient pediatric visits for AD; 34% of these involved the prescription of topical corticosteroids. From 2001 to 2004, there were 4.6 million AD visits, of which 25% involved the prescription of topical corticosteroids, although the decline was not significant. The researchers suggested that steroid phobia of parents or physicians may limit steroid use. "Misunderstandings about the use and adverse effects of topical corticosteroids … may also contribute significantly to the undertreatment of pediatric AD," the researchers wrote.
They used data on outpatient encounters by patients aged 18 years or younger compiled from the National Ambulatory Medical Care Survey (NAMCS) and the National Hospital Ambulatory Medical Care Survey (NHAMCS) databases between 1997 and 2004.
There were about 620,000 annual AD visits in 1997, and the number peaked at 1.7 million in 2003. The increase in AD visits per year was statistically significant. By 2004, the number had declined to 850,000.
"Although this peak in 2003 may be an anomaly, a potential explanation for this finding may be related to the introduction of the topical calcineurin inhibitors in 2000 and 2001," the researchers wrote. "With increased public knowledge of topical calcineurin inhibitors, parents who had previously not seen a physician for their child's AD may have potentially sought this novel treatment."
However, they noted that there was an insufficient number of records in the database to allow a statistical analysis of this trend.
Between 1997 and 2000, 14% of AD visits involved the prescription of antihistamines, which increased to 21% from 20012004. The increase was not statistically significant. Topical tacrolimus (Protopic) and pimecrolimus (Elidel) were prescribed in 10% and 13% of AD visits between 2001 and 2004. Between 1997 and 2004, oral corticosteroids were prescribed in 17% of the 6.7 million AD visits (excluding those involving asthma). It was possible for more than one drug to be prescribed per visit.
The researchers also looked specifically at children younger than 2 years. Between 1997 and 2000, there were 0.7 million AD visits for this age group; there were 1.3 million between 2001 and 2004. Of these visits, 21% and 24%, respectively, involved the prescription of topical corticosteroids.
Interestingly, in the same age group, 8% and 7% of AD visits between 2001 and 2004 involved prescriptions of tacrolimus or pimecrolimus, respectively. "In this study, we found similar rates of use of topical corticosteroids and topical calcineurin inhibitors in patients who were younger than 2 years (24% vs. 22%)," the researchers said. Calcineurin inhibitors are indicated for the short-term or intermittent treatment of mild to moderate AD (topical pimecrolimus) or moderate to severe AD (topical tacrolimus) in patients older than 2 years.
The demographics of pediatric AD visits were similar to all pediatric visits, with the exception of race and age. Of all pediatric visits, 69% were made to a generalist, compared with 43% of pediatric AD visits, and 22% of all pediatric visits were made by children aged 25 years.
Black and Asian children were seen more frequently for the diagnosis of AD. Black children and adolescents accounted for 19% of AD visits and Asian children and adolescents accounted for 11%. In contrast, black children and adolescents accounted for 12% of all visits and Asian children and adolescents accounted for 4%. A total of 69% of all pediatric visits were by white patients, compared with only 51% of pediatric AD visits.
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