Cost-effectiveness of Prophylactic Moisturization for Atopic Dermatitis

Key Points

Question  What is the cost benefit of using moisturizers for the prevention of atopic dermatitis in high-risk newborns?

Findings  In this cost-effectiveness study, there was an incremental quality-adjusted life-year (QALY) benefit of prophylactic moisturization with 7 common moisturizers used in a 6-month window. Overall, the prophylactic use of moisturizers was determined to be cost-effective, with petroleum jelly demonstrating the best cost-benefit ratio ($353/QALY).

Meaning  Prophylactic moisturization for atopic dermatitis in high-risk newborns is likely to be cost-effective for all 7 moisturizers studied.

Importance  Emerging evidence suggests that the use of moisturizers on newborns and infants (ie, from birth to 6 months of age) is potentially helpful in preventing the development of atopic dermatitis.

Objective  To investigate the cost-effectiveness of using a daily moisturizer as prevention against atopic dermatitis among high-risk newborns.

Design, Setting, and Participants  In a cost-effectiveness analysis, the average cost of total-body moisturization using 7 common moisturizers from birth to 6 months of age was determined for male and female infants. We assumed the same unit of weight per moisturizer used for a given body surface area. Based on previously reported data (relative risk reduction of 50%), the incremental gain in quality-adjusted life-years (QALYs) was determined using a 6-month time window. The cost-effectiveness of each moisturizer was determined by assuming equal efficacy. A sensitivity analysis was conducted by varying the relative risk from 0.28 to 0.90.

Interventions  Use of prophylactic moisturizing compounds.

Main Outcomes and Measures  The primary outcomes were the incremental cost-effectiveness values ($/QALY) for each moisturizer in preventing atopic dermatitis during a 6-month time window.

Results  The calculated amount of daily all-body moisturizer needed at birth was 3.6 g (0.12 oz) per application, which increased to 6.6 g (0.22 oz) at 6 months of age. Of the 7 products evaluated, the average price was $1.07/oz (range, $0.13/oz-$2.96/oz). For a 6-month time window, the average incremental QALY benefit was 0.021. The sensitivity analysis showed that the incremental gain of QALY ranged from 0.0041 to 0.030. Petrolatum was the most cost-effective ($353/QALY [95% CI, $244-$1769/QALY) moisturizer in the cohort. Even assuming the lowest incremental QALYs for the most expensive moisturizer, the intervention was still less than $45 000/QALY.

Conclusions and Relevance  Overall, atopic dermatitis represents a major health expenditure and has been associated with multiple comorbidities. Daily moisturization may represent a cost-effective, preventative strategy to reduce the burden of atopic dermatitis.

Atopic dermatitis is the most common chronic inflammatory skin condition worldwide with a prevalence ranging from 8.7% to 18.1% for children 17 years of age or younger.¹ Almost half of affected individuals first develop atopic dermatitis during the first year of life, and the majority during the first 5 years of life.² The atopic march, the propensity for asthma and other allergic disorders to develop after the onset of atopic dermatitis, occurs in approximately half of these pediatric patients with atopic dermatitis.³ Both lesional skin and nonlesional skin in atopic dermatitis have a defective barrier, as measured by transepidermal water loss. Abnormalities in transepidermal water loss at 2 days of age are predictive of the development of clinical atopic dermatitis, particularly when mutations in filaggrin, a critical protein in skin barrier function, are found. Loss-of-function mutations in filaggrin predispose to an atopic phenotype, including atopic dermatitis, food allergies, and asthma.⁴ In 30% of children, cytokines known to be increased in atopic dermatitis downregulate the expression of filaggrin itself.^5,6 Emerging evidence suggests that early pediatric atopic dermatitis exhibits a phenotype distinct from adult atopic dermatitis, supporting the benefit of early intervention.⁷

Recent attention has been directed toward the prevention of atopic dermatitis and atopic disease. Early studies have suggested that full-body application of moisturizers for 6 to 8 months, beginning within the first few weeks of life in high-risk infants (defined as a first-degree relative with atopic dermatitis), reduced the cumulative incidence of atopic dermatitis in a British/US cohort (relative risk, 50%) and a Japanese cohort (relative risk, 25%).^8,9 In this study, we assess the potential cost-effectiveness of prophylactic moisturization in preventing atopic dermatitis in high-risk newborns.

Because this study did not involve human participants, it was exempt from review by the Northwestern University institutional review board. Age-specific body surface area was calculated using the Mosteller formula¹⁰ and the 50th percentile heights and weights (World Health Organization growth charts for boys and girls) at 0 and 6 months of age.¹¹ Given that 30 g of topical moisturizer covers an adult with an average body surface area of 1.73 m², the ratio of moisturizer per meters squared was determined to be 17 g/m². We averaged the cost of the products at 4 major online retailers (Walmart, Amazon, Target, and Walgreens in July 2016). We included 6 moisturizers that potentially would reduce the risk of future sensitization for infantile atopic dermatitis: petroleum jelly,^12,13 Vaniply Ointment, Aveeno Eczema Therapy Moisturizing Cream, Cetaphil Moisturizing Cream, and CeraVe Moisturizing Cream.¹⁴ Sunflower seed oil, used in the study by Simpson et al,⁹ was also included. From 0 to 6 months of age, we assumed linear growth. This enabled us to determine the average body surface area requiring moisturization and then calculate the cost per application.

In brief, the quality-adjusted life-years (QALYs) for atopic dermatitis were determined using the prevalence of childhood atopic dermatitis for mild, moderate, and severe disease as previously reported¹⁵ with health utility values of 0.86 for mild disease, 0.69 for moderate disease, and 0.59 in severe disease in a pediatric population.¹⁶ A decision tree was created to visualize the alternatives to standard care for atopic dermatitis (eFigure in the Supplement). The incremental cost-effectiveness of moisturization as prophylaxis for atopic dermatitis was then calculated using the relative risk reduction of 50% determined by Simpson et al⁹ to better represent a US population with sensitivity analysis conducted assuming a relative risk ranging from 0.28 to 0.9. The $/QALY value was calculated by dividing the cost of moisturization with standard care (assumed to be $0) by the incremental QALYs. The time window of health utility was set at 6 months.

The calculated amount of daily all-body moisturizer needed at birth was 3.6 g (0.12 oz) per application, which increased to 6.6 g (0.22 oz) at 6 months of age. Of the 7 products evaluated, the average price was $1.07/oz (range, $0.13/oz-$2.96/oz) (Table). Petrolatum (Vaseline; petroleum jelly) was the most affordable ($7.30 for 6 months of use), while Vaniply Ointment was the most expensive ($173.39 for 6 months). The Table summarizes the costs and outcomes used in the incremental cost-effectiveness analysis. The incremental QALY gain of moisturizers was 0.030, 0.021, and 0.0041 for a relative risk of 0.28, 0.5, and 0.9, respectively, using a 6-month time window. The Figure demonstrates the sensitivity analysis of $/QALY with changes in relative risk. Compared with usual care and assuming equal efficacy among moisturizers, petrolatum was most cost-effective ($353/QALY), and Vaniply Ointment least cost-effective ($8386/QALY).

Our data show that moisturization from birth to 6 months of life is likely to be a cost-effective strategy for the prevention of atopic dermatitis. Even with a relative risk of only 0.9, prophylactic moisturization would still likely meet the National Institute for Health and Care Excellence of the United Kingdom’s threshold for cost-effectiveness (approximately $38 000/QALY).¹⁷ Our estimate of the incremental QALYs is based on only 6 months of benefit. Longer-term studies will reveal whether prophylactic moisturization will lead to a longer, more durable benefit with regard to the development of atopic dermatitis beyond the first 6 months of life.

There are several limitations to this analysis. First, the data surrounding the clinical efficacy of prophylactic moisturization are based on preliminary data, which are a part of a larger effort to determine the role prophylactic moisturization should play in atopic dermatitis. Second, we estimated equal efficacy across all moisturizers; there is limited available empirical data to compare the effectiveness of different moisturizers for atopic dermatitis. In the study by Simpson et al,⁹ there was an insufficient study size for a subgroup analysis of the clinical efficacy stratified by moisturizer used. Future efforts should be made to distinguish whether variations in moisturizer vehicle (ointment, cream, lotion, gel, or oil) or ingredients yield clinically significant differences. In addition, we assume the same weight of moisturizer used per application across the 7 products. Ointments such as petrolatum and Vaniply Ointment may require less amounts compared with cream or oil-based ointments to cover the same body surface area. Finally, longer-term follow-up of patients beyond the end of the study period (6 months and 8 months)^8,9 were not available; thus, the subsequent rate of atopic dermatitis development is unknown. Larger-scale studies with longer follow-up will determine whether prophylactic moisturization simply delays the onset of atopic dermatitis or alters the actual disease course.

The US annual cost for atopic dermatitis is estimated to range anywhere from $364 million to $3.8 billion, which is comparable to costs of other conditions with large economic burdens such as emphysema.^18,19 Given the predominance of children with atopic dermatitis, the cost to Medicaid is $5900 per beneficiary per year.¹⁸ Beyond the direct cost savings in preventing atopic dermatitis, preserving the skin barrier early in life for high-risk individuals may theoretically reduce the risk of developing other atopic diseases. For instance, neonatal skin barrier dysfunction is associated with food allergies at 2 years of age.²⁰ Furthermore, prophylactic moisturization may mitigate the risk of the occurrence of a growing list of atopic dermatitis comorbidities, which include sleep disturbances, obesity, anemia, and attention-deficit/hyperactivity disorder.^21-23 Prophylactic moisturization has decreased mortality by 32% for preterm babies in a developing country by preventing nosocomial sepsis,¹² and thus providing the precedent for a large-scale moisturization campaign.

The future for atopic dermatitis prevention is bright given the emerging biologics expected to come to market in the next few years. However, the US health care system will continue to shift toward more cost consciousness. Although the use of moisturizers based on preliminary efficacy data is cost-effective from a health system perspective, insurers do not cover moisturizers for patients with atopic dermatitis. Thus, out-of-pocket expenses for these interventions represent a significant economic burden for many families. In one recent study,²⁴ an average of 35% of a family’s discretionary income was spent out of pocket on atopic dermatitis, with moisturizers representing the single highest medication expense. Currently, therapy for atopic dermatitis is reactive. Prophylactic moisturization would represent an attractive preventative health strategy against atopic dermatitis from both a medical and economic perspective.

Accepted for Publication: October 5, 2016.

Corresponding Author: Shuai Xu, MD, MSc, Department of Dermatology, Northwestern University Feinberg School of Medicine, 676 N St Clair St, Ste 1600, Chicago, IL 60611 (stevexu@northwestern.edu).

Published Online: December 5, 2016. doi:10.1001/jamapediatrics.2016.3909

Author Contributions: Dr Xu and Ms Immaneni had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Xu, Paller, Silverberg, Lio.

Acquisition, analysis, or interpretation of data: Xu, Immaneni, Hazen, Paller, Silverberg.

Drafting of the manuscript: Xu, Immaneni.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Xu, Silverberg.

Administrative, technical, or material support: Immaneni, Hazen.

Supervision: Xu, Paller, Silverberg, Lio.

Conflict of Interest Disclosures: Dr Xu is founder and equity owner of a website providing safe product recommendations for patients with atopic dermatitis. The website has no financial relationships with any manufacturers of skin care products. Dr Xu reports a one-time travel award from Beiersdorf Inc, makers of Aquaphor, in 2015 to present research at a medical conference. He has no further financial relationships with Beiersdorf Inc. Dr Lio has served as a consultant and/or advisor for the following companies: Anacor/Pfizer, Exeltis, Galderma, Johnson & Johnson, Pierre Fabre, Regeneron, Sanofi, Theraplex, and Valeant. No other disclosures are reported.