Optimal practice review: recommendation reminders detail

Recommendation reminder 2: It is recommended that where more than one alternative topical corticosteroid is considered clinically appropriate within a potency class, the drug with the lowest acquisition cost should be prescribed, taking into account pack size and frequency of application.

Guidance:Atopic dermatitis (eczema) - topical steroids
Date issued:August 2004

Atopic eczema (also known as atopic dermatitis) is a chronic relapsing skin condition characterised by intense itching, dry skin, redness and inflammation. Estimates of prevalence vary but suggest that the condition may affect as many as 15-20% of school-age children and 2-10% of adults. Most people with atopic eczema experience mild disease; only around 2-4% of people with eczema have a severe form of the disease. Sixty per cent of eczema cases occur before the age of one; by adulthood, many patients will have grown out of the condition although may retain a propensity for eczema later in life. The incidence of eczema has been increasing in recent years.

The impact of atopic eczema on quality of life can be considerable, and varies according to disease severity. In addition to the burden imposed by daily treatment, the condition can affect everyday activities such as work or school and social relationships. Furthermore, people with atopic eczema may also experience anxiety, depression and other psychological problems. Sleep disturbance is common, especially during flare-ups, which in turn can lead to problems with irritability and lack of concentration. Severe atopic eczema in children can also have a significant impact on family life, with parents/carers having to cope with the demands associated with caring for a child with a chronic illness.

Management of atopic eczema takes place predominantly in primary care, and aims to relieve symptoms and prevent complications such as infections until remission occurs. Providing people with good-quality information is essential to successfully managing and treating atopic eczema. Referral to secondary care is advised only if the condition is severe and has not responded to appropriate therapy.

Topical corticosteroids are the first-line treatment for flare-ups of atopic eczema. In order to reduce exposure to topical corticosteroids, they are used only intermittently to control exacerbations. In its guidance on the frequency of use of topical corticosteroids, NICE and its advisory committee considered a total of 30 preparations (see NICE guidance). There are varying recommendations about the frequency of application. The 'British national formulary' (BNF) states that 'corticosteroid preparations should normally be applied once or twice daily. It is not necessary to apply them more frequently'. Although there are few empirical data to assess the patterns of prescribing, it appears that a twice-daily regimen is the most widespread approach to the use of topical corticosteroids in atopic eczema. However, some topical corticosteroids are licensed for more frequent use: up to four times a day.

Based on the evidence base reviewed, NICE recommended that topical corticosteroids are used no more frequently than twice daily and that, within the same potency class, the clinically appropriate corticosteroid with the lowest acquisition cost should be used in preference to more expensive alternatives. Because of the high acquisition cost of some products licensed solely for once-daily application twice-daily application of other products can be less costly than once-daily application.

More evidence is needed

More information on the effectiveness and safety of the different topical corticosteroid products will support more efficient use of resources across the NHS in the future:

  • Appropriate trials are required to establish whether once-daily use of the older twice-daily products is equivalent to the once-daily-only products of the same potency.
  • Long-term follow-up is necessary to assess adverse effects, such as skin atrophy, associated with the different topical corticosteroid products.

Resource implications

The wide range of topical corticosteroid products available and their varied prices make for many possible prescribing scenarios. The availability of specifically marketed once-daily topical corticosteroids, which are priced much higher than other generic and proprietary products, makes a once-daily regimen using these products more costly. Information is not readily available on current prescribing patterns of topical corticosteroids in patients with atopic eczema. There is also limited information on the quantity of product used per treatment regimen. Consequently it is not possible, with any certainty, to establish baseline information on which to base estimates of the resource impact of changes in prescribing between preparations of different acquisition costs. Furthermore, such cost savings will be relatively small at the patient level, and issues related to pack size and product waste can easily erode any potential cost saving. However, given the large patient group with atopic eczema, there may be opportunities for significant savings to the NHS on products prescribed, particularly at a primary care level, because this is where most prescribing of topical corticosteroids is likely to occur.

An illustrative scenario is explored below. The estimate is based on a number of assumptions used in the calculations, and so should be interpreted cautiously. The underlying assumptions are that patients have 2-4 (or 3 on average) flare-ups a year, that they throw away any unused products after each flare-up and that patients applying topical corticosteroids once daily would use either 50% or 75% of the amount they would use if they were applying the product twice daily. These potential savings assume that all the patient prescription costs are met by the NHS. In practice, however, many patients may receive only one prescription per year, because they may not discard their unused products. Consequently, the figures in the scenario below are likely to be an estimate of the maximum cost savings to the NHS.

Where a prescribing practice of one of the newer once-daily-only products can appropriately be altered to twice-daily use of one of the older, cheaper topical corticosteroids of the same potency, cost savings have been estimated to range from 300,000 to 600,000 (excluding VAT) for a patient group of 100,000 people with atopic eczema.

This page was last updated: 18 October 2007

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Copyright 2014 National Institute for Health and Care Excellence. All rights reserved.