Chapter 17 QOL of AD Patients
Quality of life in patients with atopic dermatitis: Impact of tacrolimus ointment
By M Kawashima published in the International Journal of Dermatology 2006, 45, 731–736
This is a paper written by Dr. Kawashima (Tokyo Women's Medical University) in 2006. He took a questionnaire method and compared QOL (quality of life) between atopic dermatitis patients with steroid phobia (fear of topical steroid application). He also compared QOL of the steroid phobia group before and after topically applying Protopic.
Quality of life in patients with atopic dermatitis: Impact of tacrolimus ointment
By M Kawashima published in the International Journal of Dermatology 2006, 45, 731–736
This is a paper written by Dr. Kawashima (Tokyo Women's Medical University) in 2006. He took a questionnaire method and compared QOL (quality of life) between atopic dermatitis patients with steroid phobia (fear of topical steroid application). He also compared QOL of the steroid phobia group before and after topically applying Protopic.
The general population consists of healthy subjects. AD indicates atopic dermatitis patients, 49 of which are confirmed to have steroid phobia. QOL ratings in AD patients including those with steroid phobia was lower than that in healthy subjects.
In the steroid phobia group, 35 people accepted applying protopic externally, which significantly improved their QOL. This is the outline of this paper.
I imagine Dr. Kawashima initially expected the steroid phobia group would have a lower QOL compared to the whole AD group. If QOL had risen to the level of the whole of AD patients after externally applying protopic ointment, he could have gained a favorable conclusion that Protopic is effective for improving the QOL of the steroid phobia group. What makes this paper short of crispness is that significant QOL difference was not found between the whole AD group and the steroid phobia group (the text includes the sentence that the QOL of the steroid phobia group was a little lower than that of the whole AD group, but it did not seem statistically significant). I’d like to suggest, “Why don’t you administer Protopic instead of steroid as to the whole AD group if it has improved QOL of the steroid phobia group.” Moreover, those who accepted the Protopic therapy was 35 out of 49 patients in the steroid phobia group, and 14 (29%) were left untreated. I think he should have mentioned what kind of measures he would take for these 14 patients.
In reading this simple paper, I noticed the word “steroid phobia” was frequently used. Though this is a short paper of 6 pages, I came across this word 7 times in Abstract and 23 times throughout the paper.
The following is the excerpt from Discussion.
----- Excerpt -----
Topical corticosteroids have been the mainstay of treatment for AD in both adults and children for nearly 50 years. However, steroid phobia related to worry about the adverse events of steroids has become a problem in Japan. In such patients, alternative treatment options may be required. Tacrolimus ointment has been established as one of the treatments for AD. Because tacrolimus has a different mechanism of action than corticosteroids and is not associated with the same adverse events, it may be an appropriate and effective treatment for patients unable or unwilling to use topical corticosteroids owing to steroid phobia.
----- End of excerpt -----
In spite of such a frequent use, he is not referring to why patients feel steroid phobia and resist to using steroids for treatment. “When patients have steroid phobia, Protopic can be an alternative option” is his rhetoric.
I introduced this paper, because I expect this rhetoric would be conveniently used by the Japanese Dermatological Association (JDA) for a while. Different from Dr. Cork et al. who revealed that topical steroids, which effectively suppress inflammation in the short term, are likely to destroy the skin barrier, causing rebound flare after discontinuation (steroid addiction). His paper does not think over or comment on topical steroid application manner from the side of dermatologists. Dr. Kawashima’s position is considering Protopic as an alternative medicine just because patients are obsessed with steroid phobia and stubbornly reject steroids.
Behind the word of steroid phobia, he does or makes readers stop thinking more. This is a very visionary manner of communication.
He’s like an emperor with no clothes on. He may be lionized by dermatologists blindly following the JDA’s policy for the time being. But it won’t take long before everybody notices that the emperor is naked like a newborn baby.
The following is the summary of the speech delivered by Dr. Kawashima at the JDA Central Japan Branch Academic Conference in 1998. (Sentences in blue are my impression.)
----- Excerpt -----
Title:Topical Corticosteroids not Guilty
(What a title! Well it’s true in a sense. The problem is not steroids but dermatologists who administer them.)
Some dermatologists express negative opinions against topical corticosteroid therapy for treating atopic dermatitis (AD). Such opinions are favorable for mass media that repeatedly feature drug disaster or medical mishaps to get public attention. They also provide a good reason for folk medicine therapists who deny existing medical treatment. As a result, patients are unnecessarily scared and made to express a strong distaste for steroids, which significantly deteriorates treatment effects as well as QOL of patients. AD is a genetic disease and it is impossible to eliminate all the causative factors. It is natural to use topical corticosteroids when they can most effectively relieve AD patients’ symptoms and it usually goes well. Dermatologists who encouraged the topical corticosteroid withdrawal should have predicted the outcome with a clear foundation before starting it. They should be blamed for making many patients suffer from hardship after discontinuation.
----- End of excerpt -----
I think Dr. Kawashima and his followers should be blamed as they failed to notice (or refused to admit) the phenomenon of addiction or rebound due to the long-term use of topical corticosteroids and continued to propagate that patients who try to withdraw from steroid are miserable people obsessed with unscientific idea, which threw them into further despair. As a result, patients addressing withdrawal were exposed to the worst social QOL. If the mechanism of steroid addiction is figured out more specifically in future, it may evolve into a very big drug disaster problem. As I stated in the previous chapters, addiction and rebound cases have been clinically observed and reported for the past 20 years.
Dr. Kawashima headed preparation of the Guideline for Diagnosis and Treatment of Atopic Dermatitis (JDA magazine Vol. 110, 1109-1104,2000), which includes the following phrase implying Dr. Kawashima’s notion about steroid phobia.
----- Excerpt -----
Misunderstandings regarding topical corticosteroids (mostly derived from confusion with adverse effects of systemic steroids, aggravation of AD flare itself or topical corticosteroid side effects) causes fear and refusal for topical corticosteroids, which often lead to poor compliance.
----- End of excerpt -----
There is no reference to addiction. He seems to have either unnoticed steroid addiction or intentionally omitted the word.
The latest JDA guideline revised in 2008 does not list Dr. Kawashima’s name as a preparation committee member with Dr. Takehara (Kanazawa University) still included. Seeing this, I suspect he is trying to pull out of work noticing the seriousness of the addiction problem. I feel that frequent use of the word “steroid phobia” in his paper might be an expression of Dr. Kawashima’s potential “fear” for the fact that steroid addiction mechanisms have been clarified and reported in overseas papers one after another.
I’d like dermatologists involved in guideline preparation to make a revision based on the correct understanding of steroid addiction as early as possible. I believe this is the best and only way to recover the trust in dermatology.
I imagine Dr. Kawashima initially expected the steroid phobia group would have a lower QOL compared to the whole AD group. If QOL had risen to the level of the whole of AD patients after externally applying protopic ointment, he could have gained a favorable conclusion that Protopic is effective for improving the QOL of the steroid phobia group. What makes this paper short of crispness is that significant QOL difference was not found between the whole AD group and the steroid phobia group (the text includes the sentence that the QOL of the steroid phobia group was a little lower than that of the whole AD group, but it did not seem statistically significant). I’d like to suggest, “Why don’t you administer Protopic instead of steroid as to the whole AD group if it has improved QOL of the steroid phobia group.” Moreover, those who accepted the Protopic therapy was 35 out of 49 patients in the steroid phobia group, and 14 (29%) were left untreated. I think he should have mentioned what kind of measures he would take for these 14 patients.
In reading this simple paper, I noticed the word “steroid phobia” was frequently used. Though this is a short paper of 6 pages, I came across this word 7 times in Abstract and 23 times throughout the paper.
The following is the excerpt from Discussion.
----- Excerpt -----
Topical corticosteroids have been the mainstay of treatment for AD in both adults and children for nearly 50 years. However, steroid phobia related to worry about the adverse events of steroids has become a problem in Japan. In such patients, alternative treatment options may be required. Tacrolimus ointment has been established as one of the treatments for AD. Because tacrolimus has a different mechanism of action than corticosteroids and is not associated with the same adverse events, it may be an appropriate and effective treatment for patients unable or unwilling to use topical corticosteroids owing to steroid phobia.
----- End of excerpt -----
In spite of such a frequent use, he is not referring to why patients feel steroid phobia and resist to using steroids for treatment. “When patients have steroid phobia, Protopic can be an alternative option” is his rhetoric.
I introduced this paper, because I expect this rhetoric would be conveniently used by the Japanese Dermatological Association (JDA) for a while. Different from Dr. Cork et al. who revealed that topical steroids, which effectively suppress inflammation in the short term, are likely to destroy the skin barrier, causing rebound flare after discontinuation (steroid addiction). His paper does not think over or comment on topical steroid application manner from the side of dermatologists. Dr. Kawashima’s position is considering Protopic as an alternative medicine just because patients are obsessed with steroid phobia and stubbornly reject steroids.
Behind the word of steroid phobia, he does or makes readers stop thinking more. This is a very visionary manner of communication.
He’s like an emperor with no clothes on. He may be lionized by dermatologists blindly following the JDA’s policy for the time being. But it won’t take long before everybody notices that the emperor is naked like a newborn baby.
The following is the summary of the speech delivered by Dr. Kawashima at the JDA Central Japan Branch Academic Conference in 1998. (Sentences in blue are my impression.)
----- Excerpt -----
Title:Topical Corticosteroids not Guilty
(What a title! Well it’s true in a sense. The problem is not steroids but dermatologists who administer them.)
Some dermatologists express negative opinions against topical corticosteroid therapy for treating atopic dermatitis (AD). Such opinions are favorable for mass media that repeatedly feature drug disaster or medical mishaps to get public attention. They also provide a good reason for folk medicine therapists who deny existing medical treatment. As a result, patients are unnecessarily scared and made to express a strong distaste for steroids, which significantly deteriorates treatment effects as well as QOL of patients. AD is a genetic disease and it is impossible to eliminate all the causative factors. It is natural to use topical corticosteroids when they can most effectively relieve AD patients’ symptoms and it usually goes well. Dermatologists who encouraged the topical corticosteroid withdrawal should have predicted the outcome with a clear foundation before starting it. They should be blamed for making many patients suffer from hardship after discontinuation.
----- End of excerpt -----
I think Dr. Kawashima and his followers should be blamed as they failed to notice (or refused to admit) the phenomenon of addiction or rebound due to the long-term use of topical corticosteroids and continued to propagate that patients who try to withdraw from steroid are miserable people obsessed with unscientific idea, which threw them into further despair. As a result, patients addressing withdrawal were exposed to the worst social QOL. If the mechanism of steroid addiction is figured out more specifically in future, it may evolve into a very big drug disaster problem. As I stated in the previous chapters, addiction and rebound cases have been clinically observed and reported for the past 20 years.
Dr. Kawashima headed preparation of the Guideline for Diagnosis and Treatment of Atopic Dermatitis (JDA magazine Vol. 110, 1109-1104,2000), which includes the following phrase implying Dr. Kawashima’s notion about steroid phobia.
----- Excerpt -----
Misunderstandings regarding topical corticosteroids (mostly derived from confusion with adverse effects of systemic steroids, aggravation of AD flare itself or topical corticosteroid side effects) causes fear and refusal for topical corticosteroids, which often lead to poor compliance.
----- End of excerpt -----
There is no reference to addiction. He seems to have either unnoticed steroid addiction or intentionally omitted the word.
The latest JDA guideline revised in 2008 does not list Dr. Kawashima’s name as a preparation committee member with Dr. Takehara (Kanazawa University) still included. Seeing this, I suspect he is trying to pull out of work noticing the seriousness of the addiction problem. I feel that frequent use of the word “steroid phobia” in his paper might be an expression of Dr. Kawashima’s potential “fear” for the fact that steroid addiction mechanisms have been clarified and reported in overseas papers one after another.
I’d like dermatologists involved in guideline preparation to make a revision based on the correct understanding of steroid addiction as early as possible. I believe this is the best and only way to recover the trust in dermatology.