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Keywords:

  • atopic dermatitis;
  • health services research;
  • medical care;
  • secondary data analysis;
  • treatment

Summary

  1. Top of page
  2. Summary
  3. Introduction
  4. Methods
  5. Results
  6. Commentary
  7. Conclusions
  8. Declaration of performing study according to ethical standards
  9. Acknowledgments
  10. Conflicts of interest
  11. References

Background: Despite the high prevalence, morbidity and economic burden of atopic eczema (AE), data on outpatient care of affected patients are missing. Methods: Utilizing a population-based administrative health care database from Saxony, Germany, this study describes outpatient care and medical treatment of AE by different medical disciplines in 2003 and 2004 by means of a representative sample of 11,555 patients with AE.

Results: About 60% of all patients with AE seeking outpatient care were adults. Of the adults 66% and among children 51% consulted a dermatologist at least once within the study period. More than 50% of patients in all age groups received potent topical steroids. Of all patients 8% and 3% received topical pimecrolimus and topical tacrolimus, respectively. More than 10% of patients received systemic steroids, while less than 0.1% was given cyclosporine. The mean annual amount of topical anti-inflammatory treatment per patient was about 40 grams.

Conclusions: Unexpectedly high proportions of patients with AE received potent topical and systemic steroids. The average total amount of prescribed medications was low. This study suggests insufficient care and medical treatment of patients with AE in routine practice.


Introduction

  1. Top of page
  2. Summary
  3. Introduction
  4. Methods
  5. Results
  6. Commentary
  7. Conclusions
  8. Declaration of performing study according to ethical standards
  9. Acknowledgments
  10. Conflicts of interest
  11. References

Despite high prevalence and morbidity of atopic eczema (AE; synonymous with atopic dermatitis and neurodermatitis) in children and adults as well as the known high social medical and health economic significance, no data exist as of yet on the actual medical treatment and on outpatient care of patients with AE by dermatologists, pediatricians and general practitioners, i. e. those professionals who probably often treat patients with AE [1–5].

Such health service epidemiologic and health economic data are a prerequisite for improved understanding of the impact of AE in routine outpatient care and thus for an evidence-based allocation of resources in the health care system [6]. The present study utilizes for the first time routinely documented data on diagnosis, services provided and prescriptions based on individual insured patients in the German health care system in the field of dermatology to describe on the actual outpatient medical care of patients with AE.

The goal of the present study is to gain knowledge on (1) the utilization of outpatient medical services by patients with AE and (2) the actual medical treatment of patients of all age groups with AE prescribed by the various specialties.

Methods

  1. Top of page
  2. Summary
  3. Introduction
  4. Methods
  5. Results
  6. Commentary
  7. Conclusions
  8. Declaration of performing study according to ethical standards
  9. Acknowledgments
  10. Conflicts of interest
  11. References

Study type

The basis of the present secondary data analysis is a complete survey of physicians’ services data by the Association of Statutory Health Insurance Physicians (Kassenärztliche Vereinigung, KV) Saxony for the government district (Regierungsbezirk, RB) Dresden and the prescription data of the AOK (Local Health Care Fund) Saxony from the years 2003 and 2004.

Data base

The data of the KV include information on physician invoices of each treated case in the time period from 01.01.2003 until 31.12.2004 of all office-based physicians in the government district Dresden. The invoices include data of the patient (insurance number, date of birth, gender, first name, zip code of place of residence, insurance status), the claimed services of each case (disease according to ICD-10, item and point value in the doctors’ fee scale, EBM) as well as information on the provider (e.g. specialty). For the time period from Jan. 1, 2003 and Dec. 31, 2004 the KV possesses data on 2,165,771 patients with about 23 million invoices.

The AOK Saxony provided all corresponding prescription data on all insured patients who were in physicians’ treatment in the years 2003 and 2004 (n = 1,837,783). The data fields contain information on the prescribed medications (anatomic-therapeutic-chemical classification code [ATC], prescribed amount, pharmacy sale prices, date of the prescription), on the prescribing physician (physician number) and on the patient treated (insurance number, year of birth, gender).

By connecting invoice and patient-based reimbursement claims data of the KV with the corresponding prescription data of the AOK it is possible to attain a comprehensive depiction of the actual medical care and pharmacologic therapy in routine outpatient care. The source population of the study collective of patients with AE are 257,347 patients insured by the AOK who were in physicians’ care in the time period 2003/2004 in the government district Dresden.

According to the guideline “Good Practice of Secondary Data Analysis”[7] an a priori internal diagnosis validation was undertaken to avoid misclassification bias. The study evaluation consisted of 11,555 patients where the diagnosis AE (ICD-10: L20) was made at least twice in different quarters in the study period or by at least two different physicians in one quarter. Insured patients for whom the diagnosis AE was encoded only once in the study time period were not included in the analysis, as these were presumably often only suspected diagnoses or diagnoses of exclusion whose consideration in the analysis could lead to systematic errors, e.g. in overestimation of the proportion of patients not treated [8].

Using this cohort of 11,555 patients with AE we examined:

  • 1
    How often patients were in outpatient treatment due to AE,
  • 2
    Which proportion of patients was cared for by dermatologists, pediatricians, general practitioners or internists and which effect age and gender of the patient had on this,
  • 3
    Which medications were used to treat patients with AE and what effect patient age (categories: 0–2 years; 3–11 years; 12–17 years; 18–64 years; ≥ 65 years) and gender had on this, and
  • 4
    What amounts of anti-inflammatory preparations were prescribed per patient to treat AE.

Anti-eczematous therapies were grouped according to ATC code and analyzed and classified according to groups of the active ingredient. Topical corticosteroids (TCS) were classified according to their antiinflammatory potency using the German classification of Niedner (class I: weak, class II: medium, class III: strong, class IV: very strong) [9]. Systemic corticosteroids are administered for a multitude of other diseases besides AE. Frequent diseases (besides AE) that are typical or common indications for systemic corticosteroids include chronic obstructive pulmonary disease (ICD-10 J44), chronic bronchitis (J42), reactive arthritides (M02), inflammatory polyarthropathies (M05–M14), systemic connective tissue diseases (M30–M36), urticaria (L50), pseudocroup (J38.5), Crohn disease (K50) and ulcerative colitis (K51) [10]. Our goal was a careful estimation of the proportion of patients with AE treated with systemic corticosteroids for the AE. Therefore, it was assumed that the steroid medication was prescribed for AE only in those patients who had none of the above-mentioned competing indications for systemic corticosteroids. All data present cannot be assigned to individual patient so that data protection regulations are observed [6]. For the performance of the present study approval was granted by the responsible ethics commission which also includes all relevant aspects of data protection.

Statistical methods

Statistical analysis was done on a descriptive or explorative basis. All statements on age pertain to age on Dec. 31, 2003. The distribution of continual variables between subgroups was compared using t-test or Wilcoxon rank sum test, frequencies using Chi-square test. Statistical analysis was performed with Stata 8.0 for Windows.

Results

  1. Top of page
  2. Summary
  3. Introduction
  4. Methods
  5. Results
  6. Commentary
  7. Conclusions
  8. Declaration of performing study according to ethical standards
  9. Acknowledgments
  10. Conflicts of interest
  11. References

The cohort of 11,555 patients with AE consisted to about 60% (n = 6,946) of adults (≥ 18 years) and to about 40% (n = 4,609) of children. Of the adults 70.7% (n = 4,911) and of the children and adolescents 52.9% (n = 2,439) were female.

In 33% of all patients (n = 3,839) the diagnosis AE was documented on two invoices in the years 2003 and 2004, 18% (n = 2,120) visited physicians due to AE in three quarters, 23% of patients (n = 2,609) presented in four or five quarters and 19% of patients (n = 2,230) were in outpatient medical care at least six times.

Specialties treating AE

Among children and adolescents about one-third (n = 1,494) were exclusively in the care of pediatricians for AE, 18.1% 8n = 832) were treated exclusively by dermatologists and further 23% of children (n = 1,058) were in the care of both dermatologists and pediatricians for AE. About 11% of affected children (n = 528) were exclusively treated by general practitioners and 6% (n = 263) by general practitioners and dermatologists (Figure 1).

image

Figure 1. Proportion of children and adolescents with atopic eczema treated by dermatologists, pediatricians and/or general physicians (n = 4,609; time period 2003–2004).

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Of all children and adolescents (n = 2,373) 51% consulted a dermatologist due to AE at least once in the observation period and about 62% (n = 2,873) a pediatrician. Boys significantly more often visited a pediatrician (65.9% vs. 59.1%; p < 0.001), girls significantly more often a dermatologist for treatment of AE (54.0% vs. 48.8%; p < 0.001). Of adults about one-half (n = 3,249) exclusively consulted dermatologists due to AE. A further 12% of affected patients were treated by dermatologists together with general practitioners. About 30% of patients were treated exclusively by general practitioners and just under 4% (n = 253) exclusively by internists (Figure 2).

image

Figure 2. Proportion of adult patients with atopic eczema treated by dematologists, general practitioners and/or internists (n = 6,946; time period 2003–2004).

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The proportion of women with AE that consulted dermatologists was significantly higher with 65.6% than men (60.7%; p < 0.001). In contrast, men were significantly more frequently in the care of general practitioners for AE (46.6% vs. 42.7%; p < 0.001).

Medical treatment of children and adults with AE

The mean total amount of topical anti-inflammatory preparations (TCS, TCI, tar preparations) per patient with the diagnosis AE was 45 g in 2003 and 41 g in 2004.

No antieczematous therapy was prescribed for 17.7% of the patients during the entire observation period. Emollients were prescribed for 27.0%, TCS for 63.1%, pimecrolimus cream for 7.9%, tacrolimus ointment for 3.4% and compounded formulations for 46.6%.

Among TCS patent (class III) preparations were applied most frequently (46.8% of patients). Among patients with AE 18.0% received class II TCS, 11.4% class I TCS and 3% class IV preparations. In the study period 2003/2004 an anti-histamine was prescribed at least once for 34.5% of patients. UV therapy was performed in 1.8% of patients. Systemic corticosteroids were administered to 10.2% of all patients (n = 1,176) for AE, while less than 0.1% of all patients (n = 8) were treated with cyclosporine. Figure 3 summarizes antiinflammatory topical therapy of patients with AE differentiated according to age groups. Of the zero to two-year-olds 71.4% were treated with TCS. In this age group 25.8% received class I corticosteroids, 25.8% class II corticosteroids, 49.7% class III corticosteroids and 0.4% class IV corticosteroids. In the other age groups also, significantly more than 50% of patients received corticosteroid therapy with predominantly class III preparations being employed. The proportion of patients treated with pimecrolimus cream declined continually with increasing age and was 15% in the zero to two-year-olds, 12.2% in the three to eleven-year-olds, 10.8% in adolescents, 6.4% in adults and 1.4% in senior citizens. Tacrolimus was most frequently prescribed for adolescents aged between 12 and 17 years (5.4% of cases). Tars and shale oils were prescribed in an age-independent manner for about 1% of patients. In the youngest age groups compound formulations were prescribed in 66% of cases, in older patients in about 40% of cases. UV therapy was performed in 1.9% of adolescents (12–17 years), in 2.8% of adults and in 2.0% in senior citizens (≥ 65 years).

image

Figure 3. Antiinflammatory topical therapy for patients with atopic eczema depending on age (n = 11,555; time period 2003–2004).

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Systemic corticosteroids were administered to 3.9% of adolescents, to 10.2% of adults and to 12.6% to senior citizens with AE. The mean amount of systemic corticosteroids prescribed in the study period was 58.5 g (range: 1–1,770 g). Cyclosporine was administered exclusively to adult patients with AE (n = 8). In 6% of the zero to two-year-olds and in about 20% of the patients in the other age groups no topical eczema therapy was prescribed.

With regard to eczema therapy there were only minor differences between male and female patients. There was a tendency in the age group zero to two-year-old for male patients and in the other age groups for female patients to more frequent use of TCS and topical calcineurin inhibitors (TCI).

Therapy of atopic eczema by dermatologists, pediatricians and general physicians

In children and adolescents treated exclusively by dermatologists (n = 832) medium and strong TCS were employed more frequently than in patients treated exclusively by pediatricians and general practitioners (Table 1). Pediatricians employed TCI more frequently than other specialties. The proportion of patients treated with pimecrolimus was practically identical with 7% in patients treated exclusively by general practitioners and exclusively by dermatologists (Table 1).

Table 1.  Antieczematous treatment of children and adolescents with atopic eczema by dermatologists, pediatricians and general physicians.
TherapyProportion of patients receiving medical therapy (%); according to specialty
Dermatologist (exclusively) (n = 832)Pediatrician (exclusively) (n = 1.494)General practitioner (exclusively) (n = 528)Dermatologist and pediatrician (n = 1.058)
None14.2%21.6%36.9%4.3%
Emollients30.7%44.2%22.2%52.3%
Tars0.7%1.4%0.6%1.0%
Topical corticosteroids in general61.9%52.1%45.3%76.8%
Topical corticosteroids, cl. 111.3%16.4%11.0%20.5%
Topical corticosteroids, cl. 217.2%8.2%13.5%19.4%
Topical corticosteroids, cl. 347.7%36.4%28.6%61.7%
Topical corticosteroids, cl. 41.2%0.4%0.4%0.9%
Pimecrolimus cream7.0%9.0%6.8%18.9%
Tacrolimus ointment2.4%3.2%1.3%6.4%
Compounded prescriptions51.8%37.5%20.3%68.5%
Antihistamines38.9%52.3%34.1%57.0%
UV therapy1.8%--0.9%

Adults with AE treated exclusively by dermatologists received TCS (68.1%) more frequently than those treated by general practitioners exclusively (53.7%). Dermatologists more often prescribed TCS of class II–IV. Weak (class I) TCS were in contrast prescribed for patients in the care of general practitioners. Compounded prescriptions and antihistamines were used by dermatologists more frequently than by general practitioners (Table 2). Systemic corticosteroids were administered in 8 to 9% of cases of adult patients with AE treated purely by dermatologists as well as those treated purely by general practitioners. Among dermatologists’ patients 3.0% and among patients of general practitioners 0.8% received UV therapy (Table 2).

Table 2.  Antieczematous treatment of adult patients with atopic eczema by dermatologists and general practitioners.
TherapyProportion of patients receiving medical therapy (%); according to specialty
Dermatologist (exclusively) (n = 3.249)General practitioner (exclusively) (n = 2.058)Dermatologist and general practitioner (n = 823)
None11.7%32.8%6.0%
Emollients21.0%11.3%20.8%
Tars1.1%0.4%1.2%
Topical corticosteroids in general68.1%53.7%76.6%
Topical corticosteroids, cl. 17.3%8.9%9.8%
Topical corticosteroids, cl. 223.9%13.9%25.8%
Topical corticosteroids, cl. 349.0%37.2%62.5%
Topical corticosteroids, cl. 46.3%3.1%6.2%
Pimecrolimus cream3.9%2.1%12.6%
Tacrolimus ointment2.2%0.5%7.7%
Compounded prescriptions53.7%28.7%59.9%
Antihistamines26.0%16.1%35.4%
UV therapy3.0%0.8%3.9%
Systemic corticosteroids9.1%8.4%12.2%
Cyclosporine0.1%-0.3%

Commentary

  1. Top of page
  2. Summary
  3. Introduction
  4. Methods
  5. Results
  6. Commentary
  7. Conclusions
  8. Declaration of performing study according to ethical standards
  9. Acknowledgments
  10. Conflicts of interest
  11. References

In the present study for the first time systematic data on outpatient medical care and pharmacologic treatment of children and adults with atopic eczema were analyzed on the basis of a large population-based sample. We thus close a gap in knowledge in the filed of health services research with regard to atopic eczema. The data base is formed by the complete prescription and physician services claims of 11,555 patients of all age groups with diagnosis of AE (at least two times) in the years 2003 and 2004 treated by office-based physicians of the KV Saxony in the government district Dresden. Insured patients for whom the diagnosis AE was encoded only once in the observation time period were not included in the analysis, as these presumably often constituted suspected diagnoses and diagnoses of exclusion and, taking these into consideration, could have led to systemic errors, e.g. in an overestimation of the proportion of patients not treated [8].

With a share of 60% adult patients with AE were numerically more important than children and adolescents in routine outpatient care – a fact that must be taken into consideration in specialty-specific and public discussions [11].

Treating specialties

The specialty of dermatology plays the predominant role in routine outpatient care of AE. Of adult patients with AE about two-thirds visited a dermatologist at least once because of their AE, about 50% were exclusively in the care of dermatologists and about 30% exclusively in the care of general practitioners. Among children and adolescents about 62% consulted a pediatrician at least once in the observation time period and about 50% a dermatologist at least once. It cannot be ruled out that AE is depending on specialty and/or in patient age over-or under-diagnosed, which might lead to distortions of the proportions of the various specialties in the treatment of AE. In order to keep such a false classification bias as low as possible, an internal diagnosis validation in accordance with the guideline “Good Practice of Secondary Data Analysis”[7] was undertaken.

Independent of age female patients were significantly more frequently under dermatologists’ care than male AE patients. These gender-specific differences must be considered in planning and implementing future preventive measures.

Pharmacologic treatment of patients with atopic eczema

A major advantage of the study is the fact that for commercial preparations only available on prescription complete data on prescribed amount, prescribed physician, date of prescription and price were available. In contrast, data on amount and price of compounded formulations were not available. Statements on the proportion of patients receiving topical therapy (e.g. with class III TCS) relate exclusively to the prescription of commercial preparations and thus constitute a careful estimation.

During the two year study period 82% of the 11,555 patients with AE were prescribed a topical antieczematous treatment at least once, with TCS being utilized by far the most frequently, as expected. It is notable that little difference in eczema therapy existed between the various age groups. More than 50% of patients of each age group received TCS and then predominantly class III products. Patients exclusively treated by dermatologists for AE received medium and strong TCS more frequently than those who were exclusively under the care of pediatricians or general practitioners. It can be assumed that patients treated purely by general practitioners or pediatricians had lower disease activity and were easier to treat than patients under dermatologists’ care. The proportion of patients treated with pimecrolimus cream declined steadily with increasing age and was 15% in the zero to two-year-olds, about 10% among the rest of children and adolescents, 6% in adults and less than 2% in senior citizens. Within the individual age groups, pediatricians prescribed TCI more often than dermatologists and general practitioners. In the patient population study TCI were prescribed much less frequently than in a comparable study in USA, where 23% of outpatient AE patients received TCI [12]. Presumably the “black box warning” issued by the FDA in January 2006 significantly affected the prescription of TCI, so that the present proportion of patients with AE treated with TCI is possibly lower than in the observation period of this study (2003 and 2004).

Despite convincing evidence from clinical studies [13] cyclosporine was administered to only eight adult patients (< 0.1% of all patients) and thus plays practically no role in routine care. In contrast, despite lack of evidence from studies [14] based on a conservative estimation almost 4% of adolescents, 10% of adults and 13% of senior citizens received systemic corticosteroids for AE. The present analysis thus discloses a significant gap between true pharmacologic care and evidence derived from clinical studies and indicates that the pharmacologic treatment of patients with AE in routine outpatient care frequently does not conform to guidelines [15]. In addition to the significantly lower price in comparison to cyclosporine, the experience and confidence dermatologists and general practitioners have with the use of systemic corticosteroids is a possible explanation for their widespread use for AE despite lack of evidence from studies. While it can be assumed that patients with severe AE not sufficiently controllable by topical therapy usually present to dermatologists, about 9% of patients exclusively under the care of general practitioners for antieczematous therapy received systemic corticosteroids. Cyclosporine and prednisolone can at times induce severe side effects, so that their use is only recommended for patients where topical treatments are not sufficiently effective [16]. Even though comparative numbers on the proportion of patients with AE who cannot be controlled by topical treatment are not available, the proportion of almost 10% appears to be relatively high. In an investigator-initiated randomized clinical long-term study we were recently able to show that an evidence-based treatment algorithm with the proactive use of topical anti-inflammatory agents could almost completely avoid systemic therapy in patients with severe AE [17].

In 2003 a mean of 45 g and in 2004 41 g of proprietary medications with antiinflammatory agents was prescribed for each of the 11,555 patients with AE. Comparative data on the amount of antiinflammatory agents in routine outpatient care of patients with AE are not available. In publications of RCTs in patients with AE the amounts of medications used are usually not reported. It can be safe to say that the amounts of topical medication with active ingredients are many times higher in studies than in routine care. The small amounts of active topical agents suggest possible inadequate care of patients with AE in the daily routine. A proactive antiinflammatory treatment that aims to modify the course of AE and the atopic march suggested by various studies [18–22] is not possible with actual amounts of antiinflammatory preparations prescribed.

Conclusions

  1. Top of page
  2. Summary
  3. Introduction
  4. Methods
  5. Results
  6. Commentary
  7. Conclusions
  8. Declaration of performing study according to ethical standards
  9. Acknowledgments
  10. Conflicts of interest
  11. References

A major result of by this study is that the day-to-day outpatient care of AE – even by dermatologists – apparently often does not conform to guidelines [15, 16]. A disproportionately high number of patients in all age groups were treated with strong (class III) TCS, which only should be used in moderately severe AE, when treatment with weak and medium TCS is inadequately effective [15]. The proportion of adults with AE treated with systemic corticosteroids was also unexpectedly high with over 10%. The use of highly potent active ingredients stands in contrast to the small amounts of topical preparations containing active ingredients prescribed. In interpreting the results of this study it must be remembered that the data primarily reflect routine outpatient care in Saxony and cannot be applied 1 : 1 to the whole of Germany. One argument for generalizing the results beyond the study population is the relative homogenous health political context within Germany which is presumably the major determinant of health care.

Further studies – preferably based on a nation-wide sample – are important to better understand the determinants of prescription behavior of providers and the utilization behavior of insured patients in order to optimize medical care of patients with AE by means of targeted interventions.

Declaration of performing study according to ethical standards

  1. Top of page
  2. Summary
  3. Introduction
  4. Methods
  5. Results
  6. Commentary
  7. Conclusions
  8. Declaration of performing study according to ethical standards
  9. Acknowledgments
  10. Conflicts of interest
  11. References

This study was evaluated by the responsible ethics commission according to the standards of the Declaration of Helsinki. The application to perform the study was approved.

Acknowledgments

  1. Top of page
  2. Summary
  3. Introduction
  4. Methods
  5. Results
  6. Commentary
  7. Conclusions
  8. Declaration of performing study according to ethical standards
  9. Acknowledgments
  10. Conflicts of interest
  11. References

The study was independently performed by the authors without any financial support. Our special thanks go to the Association of Statutory Health Insurance Physicians Saxony (especially Mr. Uhlig) and the AOK Plus (especially Dr. Maywald, MPH) as well as to the co-workers of the Institute of Clinical Pharmacology, Medical Faculty Carl Gustav Carus, Technical University of Dresden for providing and processing the data.

Conflicts of interest

  1. Top of page
  2. Summary
  3. Introduction
  4. Methods
  5. Results
  6. Commentary
  7. Conclusions
  8. Declaration of performing study according to ethical standards
  9. Acknowledgments
  10. Conflicts of interest
  11. References

Jochen Schmitt: none; Natalie M. Schmitt: none; Wilhelm Kirch: none; Michael Meurer: Advisory activity for Novartis, Wyeth and Botest. Lecturer for Novartis, Wyeth, Biotest, Leo Actelion, 3M and ZLB Behring.

References

  1. Top of page
  2. Summary
  3. Introduction
  4. Methods
  5. Results
  6. Commentary
  7. Conclusions
  8. Declaration of performing study according to ethical standards
  9. Acknowledgments
  10. Conflicts of interest
  11. References
  • 1
    Williams HC. Clinical practice. Atopic dermatitis. N Engl J Med 2005; 352(22): 231424.
  • 2
    Dickel H, Kuss O, Schmidt A, Schmitt J, Diepgen TL. [Incidence of occupation-related skin diseases in skin-exposure occupational groups]. Hautarzt 2001; 52(7): 61523.
  • 3
    Schmitt J, Meurer M, Klon M, Frick KD. Assessment of health state utilities of controlled and uncontrolled psoriasis and atopic eczema – A population-based study. Br J Dermatol 2007; 158(2): 3519.
  • 4
    Schmitt J, Maywald U, Schmitt NM, Meurer M, Kirch W. Cardiovascular risk factors and psychiatric comorbidity in patients with atopic eczema. A population-based case-control study. 5th Georg Rajka International Symposium on Atopic Dermatitis Kyoto Abstract-book, 47. 2008; Ref Type: Abstract.
  • 5
    Schmitt J, Csotonyi F, Bauer A, Meurer M. Determinants of treatment goals and satisfaction of patients with atopic eczema. J Dtsch Dermatol Ges. 2008; 6(6): 45865.
  • 6
    Swart E, Ihle P. Routinedaten im Gesundheitswesen – Handbuch Sekun-därdatenanalyse: Grundlagen, Methoden und Perspektiven. 1. Auflage. Verlag Hans Huber, Bern , 2005.
  • 7
    Arbeitsgruppe Erhebung und Nutzung vonSekundärdaten (AGENS) der Deutschen Gesellschaft für Sozialmedizin und Prävention (DGSMP). Gute Praxis Sekundärdatenanalyse (GPS). In: SwartE, IhleP: Routinedaten im Gesundheitswesen – Handbuch Sekundärdatenanalyse: Grundlagen, Methoden und Perspektiven. Bern : Verlag Hans Huber, 2005: 40512.
  • 8
    Köster I, Von Ferber L. Interne Diagnosevalidierung. In: Von FerberL, BehrensJ: Public Health Forschung mit Gesundheits- und Sozialdaten. Stand und Perspektiven. Sankt Augustin : Asgard-Verlag, 1997: 5564.
  • 9
    Niedner R. [External administration of glucocorticosteroids. Part 1: Administration guidelines–classification]. Fortschr Med 1992; 110(17): 3279.
  • 10
    Hatz HJ. Glucocorticoide. Immunologische Grundlagen, Pharmakologie und Therapierichtlinien. 1. Auflage. Wissenschaftliche Verlagsgesellschaft mbH, Stuttgart , 1998.
  • 11
    Schmitt J, Schmitt NM, Kirch W, Meurer M. Bedeutung des atopischen Ekzems in der ambulanten medizinischen Versorgung. Eine Sekundärdatenanalyse. Hautarzt 2008; (submitted).
  • 12
    Horü KA, Simon SD, Liu DY, Sharma V. Atopic dermatitis in children in the United States, 1997–2004: visit trends, patient and provider characteristics, and prescribing patterns. Pediatrics 2007; 120(3): e52734.
  • 13
    Schmitt J, Schmitt NM, Meurer M. Cyclosporin in the treatment of patients with atopic eczema – a systematic review and meta-analysis. JEADV 2007; 21: 60619.
  • 14
    Schmitt J, Schakel K, Schmitt N, Meurer M. Systemic treatment of severe atopic eczema: a systematic review. Acta Derm Venereol 2007; 87(2): 10011.
  • 15
    Werfel T, Aberer W, Augustin M, Biedermann T, Fölster-Holst R, Friedrichts F. Neurodermitis (Leitlinie AMWF). Arbeitsgemeinschaft der wissenschaftlichen Medizinischen Fachge-sellschaften (AWMF) 2008; Nr. 013/027.
  • 16
    Ellis C, Luger T, Abeck D, Allen R, Graham-Brown RA, De Prost Y, Eichenfield L F, Ferrandiz C, Giannetti A, Hanifin J, Koo JY, Leung D, Lynde C, Ring J, Ruiz-Maldonado R, Saurat JH. International Consensus Conference on Atopic Dermatitis II (ICCAD II): clinical update and current treatment strategies. Br J Dermatol 2003; 148 Suppl 63: 310.
  • 17
    Schmitt J, Meurer M, Schwanebeck U, Grählert X, Schäkel K. Treatment following an evidence-based algorithm versus individualised symptom-oriented treatment for atopic eczema. A randomised controlled trial. Dermatology. 2008; 217(4): 299308.
  • 18
    Wollenberg A, Reitamo S, Atzori F, Lahfa M, Ruzicka T, Healy E, Giannetti A, Bieber T, Vyas J, Deleuran M. Proactive treatment of atopic dermatitis in adults with 0.1% tacrolimus ointment. Allergy 2008; 63(6): 74250.
  • 19
    Hanifin J, Gupta AK, Rajagopalan R. Intermittent dosing of fluticasone propionate cream for reducing the risk of relapse in atopic dermatitis patients. Br J Dermatol 2002; 147(3): 52837.
  • 20
    Peserico A, Stadtler G, Sebastian M, Fernandez RS, Vick K, Bieber T. Reduction of relapses of atopic dermatitis with methylprednisolone aceponate cream twice weekly in addition to maintenance treatment with emollient: a multicentre, randomized, double-blind, controlled study. Br J Dermatol 2008; 158(4): 8017.
  • 21
    Berth-Jones J, Damstra RJ, Golsch S, Livden JK, Van Hooteghem O, Allegra F, Parker CA. Twice weekly fluticasone propionate added to emollient maintenance treatment to reduce risk of relapse in atopic dermatitis: randomised, double blind, parallel group study. BMJ 2003; 326(7403): 1367.
  • 22
    Virtanen H, Remitz A, Malmberg P, Rytila P, Metso T, Haahtela T, Reitamo S. Topical tacrolimus in the treatment of atopic dermatitis – does it benefit the airways? A 4-year open follow-up. J Allergy Clin Immunol 2007; 120(6): 14646.