Dermatology: Practical and Conceptual Original Article | Dermatol Pract Concept. 2025;15(3):5538 1 Patient Burden and Impact of Moderate-to-Severe Atopic Dermatitis in the Spanish Healthcare System: The APOLO Cross-Sectional Study Pablo De La Cueva Dobao1, Laia Curto Barredo2, Juan Francisco Silvestre Salvador3, Esther Serra-Baldrich4, Pedro Herranz Pinto5, Natalia Hernández Cano5, Francisco Javier Ortiz De Frutos6, Gastón Roustan Gullón7, Rosa María lzu Belloso8, Irene Arévalo Ortega8, Alicia González Quesada9, Manuel Galán Gutiérrez10, Yolanda Gilaberte Calzada11, Daniel Arumi Torredemer12, Noelia Llevat Felius12, Irene Hernández Martín12, Francisco José Rebollo Laserna12 1 Hospital Universitario Infanta Leonor, Madrid, Spain 2 Hospital del Mar, Ciutat Vella, Barcelona, Spain 3 Hospital General Universitario Dr. Balmis, Alicante, Spain 4 Hospital de la Santa Creu i Sant Pau, Horta-Guinardó, Barcelona, Spain 5 Dermatology department, La Paz University Hospital; Autonomous University of Madrid, Fuencarral, El Pardo, Madrid, Spain 6 Hospital Universitario 12 de Octubre, Madrid, Spain 7 Hospital Universitario Puerta de Hierro, Majadahonda Madrid, Spain 8 Hospital Universitario de Basurto-Montevideo Etorb, Bilbo, Bizkaia, Spain 9 Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas de Gran Canaria, Spain 10 Hospital Universitario Reina, Córdoba, Spain 11 Hospital Universitario Miguel Servet, Zaragoza, Spain 12 PFIZER S.L.U., Alcobendas, Madrid, Spain Key words: atopic dermatitis, pruritus, disease burden, quality of life, healthcare resources Citation: De La Cueva Dobao P, Curto Barredo L, Silvestre Salvador JF, et al. Patient Burden And Impact Of Moderate to-- Severe Atopic Dermatitis in the Spanish Healthcare System: The APOLO Cross-Sectional Study. Dermatol Pract Concept. 2025;15(3):5538. DOI: https:// doi.org/10.5826/dpc.1503a5538 Accepted: June 9, 2025; Published: July 2025 Copyright: ©2025 De La Cueva Dobao et al. This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original authors and source are credited. Funding: None. Competing Interests: None. Authorship: All authors have contributed significantly to this publication. Scientific advisory and medical writing assistance were provided by Carla Martín Cortázar from Evidenze Health España S.L.U. during the preparation of this manuscript, according to Good Publication Practice guidelines. The responsibility for opinions, conclusions, and interpretation of data lies with the authors. Corresponding Author: Irene Hernandez Martín, PFIZER S.L.U., Avda. Europa, 20, B, 28108 Alcobendas (Madrid), Spain. E-mail: irene.hernandez@pfizer.com 2 Original Article | Dermatol Pract Concept. 2025;15(3):5538 Introduction With a prevalence of 3–5% in adults and up to 20% in chil- dren, atopic dermatitis (AD) represents the most prevalent skin disease. AD onset occurs within the first year of life in 50–60% of patients, although it also affects adults [1,2]. De- spite its relatively low mortality rate, AD can be associated with substantial morbidity and disability. Indeed, according to the Global Burden of Disease consortium, AD is ranked in the top 15 of all nonfatal diseases in terms of disability- adjusted life year (DALY) and has the highest DALY burden among all skin diseases [3]. AD typically undergoes remitting and relapsing episodes with painful flares. Consequently, successful management of the disease requires pharmacological treatment to relieve itching, pain, and flares as well as self-care practices to main- tain a healthy epidermal barrier, thus reducing AD symptoms and preventing flare-ups [4]. Persistent itching of the skin, the hallmark of AD, inter- feres with daily activities, causes sleep disorders, and ad- versely impacts patients’ quality of life [5]. Altogether, this makes AD a physical, emotional, and financial burden for patients. As it is primarily a childhood disease, family mem- bers are often affected by both the psychosocial and finan- cial implications of AD [6]. Indirect costs of managing the disease, such as doctor’s appointments, absences from work, school, or hospitalizations, also emerge as a burden on so- ciety [7,8]. Despite the importance of psychosocial well-being, the stigma, and the financial impact of AD on patients, these aspects have been poorly addressed in Spain. Data on pa- tients’ journey through the healthcare system and available treatments in clinical practice are also limited. Objectives This study aimed to provide an overview of the management and treatment of patients with moderate-to-severe AD under routine clinical practice in Spain. Our goal was to determine the burden of the disease on patients’ quality of life and their households as well as the financial burden and the impact on the Spanish healthcare system. Methods Study Design and Patients APOLO (AtoPic dermatitis - a crOss-sectionaL study on disease characteristics and impact On patients) was a multi- center descriptive cross-sectional study designed to identify the impact of moderate-to-severe AD on young and adult patients and its burden, conducted at 12 Spanish derma- tology centers following the Declaration of Helsinki and European and local requirements. The study was approved by the Ethics Committee of the Hospital General Universi- tario Gregorio Marañón (Madrid, Spain). Written informed consent was obtained from all patients (or their legal guard- ians) before their inclusion. Included in the study were consecutive patients ≥12 years of age with a diagnosis of AD with a severity level ≥3 Introduction: Atopic dermatitis (AD) is a chronic inflammatory condition associated with a signif- icant physical, psychological, and economic burden. This study aimed to determine the multidimen- sional impact of AD on patients and the Spanish healthcare system. Methods: The present multicenter descriptive cross-sectional study was conducted at 12 Spanish sites to detect clinical practice assessments and validated patient-reported measures. Results: A total of 62 patients were included (54.8% males; mean age: 33.1 years). According to the validated Investigator Global Assessment scale for AD, 61.3% and 38.7% of patients had moderate and severe AD, respectively. AD involved a mean of 43.3% body surface area, with patients reporting a median of 4.0 flares in the past year. The mean Patient-Oriented Eczema Measure (POEM) question- naire score was 19.8, indicating severe eczema. In addition, 57.1% of patients reported daily pain from scratching or skin inflammation. The mean Dermatology Life Quality Index (DLQI) was 14.3, show- ing a strong AD impact on patients’ quality of life, positively correlated with severity, pruritus, and pain. AD also affected work productivity and sleep, with over 50% of patients reporting impairments in daily activities. Treatment patterns showed predominant use of topical corticosteroids (81.5%). Al- though no patient required hospitalization in the previous year, 25% resorted to alternative therapies/ unlicensed products. Conclusions: AD profoundly impacts patients’ quality of life and entails high economic costs. This study emphasizes the need for more effective treatment strategies and an improved understanding of the AD burden to utilize public healthcare resources more efficiently. ABSTRACT Original Article | Dermatol Pract Concept. 2025;15(3):5538 3 according to the validated Investigator Global Assessment scale for AD (vIGA-AD) [9] who requested medical attention because of AD for the first time in those centers. Those who were participating in clinical trials at the time of recruitment or who had other active concomitant skin diseases that could interfere with the results (such as psoriasis and chronic ur- ticaria) were excluded. Patient recruitment was conducted from May 2022 to September 2023. Data on routine medical practice were collected during a single visit of patients to their referral center (study visit). Study Endpoints The primary endpoint was the impact of moderate-to-severe AD on patients’ health-related quality of life (HR-QoL), work productivity, sleep, household, and the symptoms of the dis- ease. This endpoint was addressed through a series of vali- dated scales and questionnaires completed by the patients at the study visit. The HR-QoL was assessed by the Dermatol- ogy Life Quality Index (DLQI) [10] and the 3-level version of the EuroQuol EQ-5D index (EQ-5D-3L) [11], while the Children’s Dermatology Life Quality Index (CDLQI) [12] was used in patients under age 16 years. The impact of the disease on work productivity was evaluated by the Work Productiv- ity and Activity Impairment Questionnaire (WPAI) [13], and sleep disturbances were evaluated using a visual analog scale (VAS) from 0 (absence of insomnia) to 10 (worst insomnia imaginable). The impact on households was only assessed in patients ≤16 years, by the Dermatitis Family Impact Question- naire (DFI) [14]. Symptoms, pruritus, and pain associated with moderate-to-severe AD were evaluated by the Patient-Oriented Eczema Measure (POEM) [15], the Peak Pruritus Numerical Rating Scale (PP-NRS) [16], and a VAS from 0 (absence of pain) to 10 (worst unbearable pain), respectively. Secondary endpoints included a description of patients’ demographic and clinical characteristics, treatment patterns for AD, and the healthcare resources consumed. To achieve these objectives, a medical chart review of patient demo- graphic and clinical data (including the body surface and areas affected by AD and disease severity, assessed by the in- vestigator using the Eczema Area and Severity Index [EASI] [17]) was conducted, and treatments used currently and in the past for AD were gathered. The main characteristics of healthcare resources used were also collected, detailing the number of hospital visits, hospitalizations due to AD in the previous year, and patients’ personal costs. Exploratory objectives included evaluating possible asso- ciations between disease severity/pruritus/pain and HR-QoL. Statistical Analysis A descriptive statistical analysis was performed on the study variables, using measures of central tendency and dispersion (mean and standard deviation [SD], median and interquar- tile range [IQR]) for quantitative variables, and frequencies and valid percentages for qualitative variables. The associ- ation between variables was measured by the Spearman’s correlation coefficient. Missing data were not considered in the analyses. All hy- pothesis tests were bilateral, and significance was considered at p<0.05. All statistical analyses were conducted using IBM SPSS Statistics version 29.0 (IBM Corp., Armonk, NY, USA). Results Patient Characteristics A total of 71 patients with AD met the selection criteria and were enrolled in the study. Nine patients were excluded be- cause of screening failure; therefore, 62 patients were assess- able for statistical analyses. As shown in Table 1, the mean (SD) age was 33.1 (12.8) years old, and 54.8% were males. Family history of AD and other allergic diseases were present in 30.4% and 18.5% of the population, respectively. Most (90.3%) patients showed at least one concomitant disease, including a history of asthma (55.4%) and a history of aller- gic rhinitis (43.4%), among others. According to the vIGA-AD, disease severity was classi- fied as moderate in 61.3% of patients and severe in 38.7%. When assessed by the EASI, which also incorporates the ex- tent of body surface area affected, the proportion of patients by disease severity was almost evenly distributed between moderate (50.0%) and severe (46.8%) AD, with 3.2% hav- ing very severe AD. Overall, the mean score on the EASI scale was 23.4 (12.2). The median (IQR) age at onset of AD was 3.0 (1.0-12.5) years of age. AD affected a mean of 43.3% (22.1) of the body surface, with 75.8% of patients having face involvement and 73.7% in skin folds. Patients reported a median of 4.0 (2.0-10.0) AD flares in the previous year (Table 2). Impact of AD on Patients’ HR-QoL, Work Productivity, Sleep, and Household The POEM showed that most patients experienced itching daily (85.2%), with bleeding (37.7%), and cracked and peeled skin (47.5% and 55.7%) during the week before the study visit (Table S1). Overall, the mean POEM score was 19.8 (6.4), indicating a severe stage of eczema. On the PP-NRS, in which 10 indicates “the worst imaginable itch” during the previous 24 hours, the mean score for the study population was 7.8 (2.1) (Table 3). Assessment of pain associated with the disease was available for 55 patients. Among them, 49 (89.1%) expe- rienced pain because of eczema. As shown in Table 3, more than half (57.1%) of patients stated experiencing pain ev- ery day. The mean pain score on the VAS, considering the 4 Original Article | Dermatol Pract Concept. 2025;15(3):5538 pain experienced in the week before the study visit, was 5.7 (3.0). Patients reported that open wounds due to scratch- ing (62.0%), skin redness and inflammation (56.0%), and fissures (48.0%) mainly caused the pain. According to the DLQI score (mean [SD] = 14.3 [7.6]), the symptoms and pain associated with AD had a very large impact on the HR-QoL of patients. The most adversely af- fected aspects of patients’ lives were their symptoms and feelings (4.4 [1.5]), followed by their daily (3.1 [2.0]) and leisure (2.4 [2.0]) activities. Spearman’s correlation analyses showed a positive and statistically significant association Table 2. Data on AD in the Study Population. Study parameter Value vIGA-AD, n (%) [N] Moderate 38 (61.3) [62] Severe 24 (38.7) [62] EASI score, mean (SD) [N] 23.4 (12.2) [62] EASI severity (grouped), n (%) [N] Moderate 31 (50.0) [62] Severe 29 (46.8) [62] Very severe 2 (3.2) [62] Age at AD onset (years), median (IQR) [N] 3.0 (1.0-12.5) [53] Body surface affected by AD (%), mean (SD) [N] 43.3 (22.1) [54] Body areas of special interest affected by AD¥, n (%) [N] Face/neck 47 (75.8) [62] Face: periocular 39 (83.0) [47] Neck 35 (74.5) [47] Face: perioral 27 (57.4) [47] Face: other 27 (57.4) [47] Intertriginous skin areas 42 (73.7) [57] Hands 30 (100.0) [30] Feet 17 (40.5) [30] Number of flares in the previous year, median (IQR) [N] 4.0 (2.0-10.0) [43] Abbreviations: AD: atopic dermatitis; EASI: Eczema Area and Severity Index; IQR: interquartile range; n: patients with event; N: number of patients with available data; SD: standard deviation; vIGA-AD: validated Investigator Global Assessment scale for Atopic Dermatitis. ¥Multiple response. Percentages can add up to more than 100%. Table 1. Characteristics of the Study Population. Characteristics Value Demographics Age (years), mean (SD) [N] 33.1 (12.8) [62] Sex (male), n (%) [N] 34 (54.8) [62] Ethnicity (Caucasian), n (%) [N] 56 (91.8) [61] BMI (kg/m2), mean (SD) [N] 25.2 (4.7) [57] Education level, n (%) [N] Primary 4 (7.7) [52] Secondary 12 (23.1) [52] Post-secondary (not tertiary) 3 (5.8) [52] Short-cycle tertiary 7 (13.5) [52] Tertiary or equivalent 16 (30.8) [52] Master’s, specialization, or equivalent 10 (19.2) [52] Professional situation, n (%) [N] Employed 34 (57.6) [59] Student 14 (23.7) [59] Unemployed 6 (10.2) [59] Self-employed 4 (6.8) [59] Retired 1 (1.7) [59] Clinical Information Family history of AD, n (%) [N] 17 (30.4) [56] Family history of other allergic diseases, n (%) [N] 10 (18.5) [54] Concomitant diseases (>20%)¥, n (%) [N] 56 (90.3) [62] History of asthma 31 (55.4) [56] History of allergic rhinitis 26 (46.4) [56] History of allergic conjunctivitis 19 (33.9) [56] History of food allergy 19 (33.9) [56] Anxiety disorder 18 (32.1) [56] Contact dermatitis 16 (28.6) [56] Smoking habit 14 (25.0) [56] Abbreviations: AD: atopic dermatitis; BMI: body mass index; n: patients with event; N: number of patients with available data; SD: standard deviation. ¥Multiple response. Percentages can add up to more than 100%. between the DLQI, and the severity of the disease (p=0.017), pruritus (p=0.003), and pain (p=0.005) experienced by patients (Table 4). Moreover, according to the EQ-5D-3L, 45.6% of pa- tients expressed moderate pain or discomfort and 47.4% experienced moderately anxious or depressed (Table S2). AD also affected patients’ work productivity, as shown in Table 5. Despite not causing absenteeism due to AD in the previous seven days, patients reported a median of 50.0% (21.3-70.0) overall work impairment caused by the disease. Similarly, AD impacted patients’ academic activity. Thirteen (25.0%) patients reported attending classes, with a median of 76.0% (30.0-79.0) overall classroom impairment caused by AD in the seven days before the study visit. The median percentage of impairment in daily activities was 55.0% (20.0-77.5), and sleep disturbances on the three nights before the study visit were moderate (mean [SD] VAS = 6.0 [3.1]). Original Article | Dermatol Pract Concept. 2025;15(3):5538 5 Treatments for AD At the study visit, 54 (87.1%) patients received treatment for AD. The most commonly used treatments were topical cortico- steroids (81.5%) and emollients (75.9%). Similarly, 59 (95.2%) patients had received at least one treatment for AD in the past, with almost all of them receiving topical corticosteroids (94.9%). After the study visit, treatment was planned for 60 (96.8%) pa- tients. Physicians recommended emollients to 88.3% of patients and topical corticosteroids to 78.3% (Table 6). Approximately 17–18% of patients also required a differ- ent treatment at the study visit and afterward for special body areas affected, mainly the face and periorbital area. Topical calcineurin inhibitors and topical corticosteroids were gener- ally recommended in these circumstances (Table S3). Burden on the Healthcare System Most patients (86.9%) were referred to the participating cen- ters by other healthcare professionals, mainly from primary Table 3. Symptoms of Patients with AD Assessed by the POEM Questionnaire, PP-NRS, and a Pain VAS. Symptoms assessment Value Total POEM score, mean (SD) [N] 19.8 (6.4) [61] POEM groups, n (%), N=61 Mild 2 (3.3) Moderate 17 (27.9) Severe 28 (45.9) Very severe 14 (23.0) Total PP-NRS score, mean (SD) [N] 7.8 (2.1) [60] Pain score (VAS), mean (SD) [N] 5.7 (3.0) [57] Patients with pain, n (%) [N] 49 (89.1) [55] Frequency of pain due to eczema or AD, n (%), N=49 Every day 28 (57.1) 5–6 days a week 8 (16.3) 3–4 days a week 6 (12.2) 1–2 days a week 3 (6.1) Less than once a week 4 (8.2) Causes of pain due to eczema or AD¥, n (%), N=50 Open wounds caused by scratching 31 (62.0) Red and inflamed skin 28 (56.0) Small cracks in the skin (fissures) 24 (48.0) Itching caused by creams or ointments 12 (24.0) AD: atopic dermatitis; n, patients with event; N: number of patients with available data; POEM: Patient Oriented Eczema Measure; PP- NRS: Peak Pruritus Numerical Rating Scale; SD: standard deviation; VAS: visual analog scale. ¥Multiple response. Percentages can add up to more than 100%. Table 4. DLQI of Patients with AD. DLQI Value Total DLQI score, mean (SD) [N] 14.3 (7.6) [58] DLQI groups, n (%), N=58 0 - 1: No effect at all on patient’s life 2 (3.4) 2 - 5: Small effect on patient’s life 5 (8.6) 6 - 10: Moderate effect on patient’s life 13 (22.4) 11 - 20: Very large effect on patient’s life 24 (41.4) 21 - 30: Extremely large effect on patient’s life 14 (24.1) Score in DLQI dimensions, mean (SD) [N] Symptoms and feelings 4.4 (1.5) [56] Daily activities 3.1 (2.0) [58] Leisure 2.4 (2.0) [57] Work and school 1.6 (1.9) [57] Personal relationships 1.9 (2.0) [57] Treatment 1.1 (1.1) [58] Variables associated with DLQI Spearman’s coefficient p-value N EASI 0.313 0.017 58 PP-NRS 0.383 0.003 57 Pain VAS 0.395 0.005 50 Abbreviations: DLQI: Dermatology Life Quality Index; EASI: Eczema Area and Severity Index; n: patients with event; N: number of patients with available data; PP-NRS: Peak Pruritus Numerical Rating Scale; SD: standard deviation; VAS: visual analog scale. care (50.9%), dermatology (31.6%), or other medical ser- vices (8.8%; clinical trial campaign, labor health, transplant unit, and so on). However, they were first diagnosed with AD by a pediatrician (40.7%), dermatologist (32.2%), or primary care physician (25.4%) (Figure 1). Patients reported having visited other healthcare centers in the past, with primary care (78.7%) and dermatology (75.4%) being the services most frequently visited (Figure 1). During the year before the study visit, the median number of AD-related visits to the pharmacy was 10.0 (4.0-15.0). The median number of visits to a dermatology-specialized center was 2.0 (0.0-4.0), while it was 0.0 (0.0-1.0) for emergencies. No patient required hospitalization in the previous year (Table S4). Some patients needed complementary diagnostic tests, listed in Table S5. Healthcare Costs Borne by Patients The overall healthcare expenses borne by patients with AD are summarized in Table S6. Briefly, 63.0% of patients needed 6 Original Article | Dermatol Pract Concept. 2025;15(3):5538 more effectively [18]. The APOLO study presents an over- view of the profile and symptoms of real-life patients with moderate-to-severe AD managed and treated at Spanish dermatology-specialized centers; presented also are the as- sociated physical, emotional, economic, and social burdens. This study shows that AD considerably impacted patients’ quality of life, accompanied by impairments in work/ academic activities, moderate sleep disturbances, and a sig- nificant burden on the Spanish healthcare system, especially in primary care and dermatology. In this real-world study, we observed an evident impact of AD on patients’ HR-QoL. According to the DLQI, nearly 65% of patients experienced a large/very large effect of AD on their lives. The mean DLQI was similar to or even higher than values reported in previous studies [19-21], support- ing that HR-QoL is severely compromised in patients with moderate-to-severe AD. These results also align with the findings from two recent real-world APOLO sub-studies conducted in Greece and Portugal [22,23]. Moreover, our data confirm that greater disease severity impacts patients’ HR-QoL more acutely, as previously demonstrated [21-24]. Itching is often the most commonly mentioned symptom for patients with AD [24]. In accordance, we observed that most patients experienced itching daily, together with high scores on the PP-NRS, and a severe eczema stage according to the POEM. This symptom may be followed by depres- sion and anxiety observed in almost half of patients in the EQ-5D-3L and showed a positive association with the DLQI. These results are consistent with those previously described in the literature [23,25,26] and highlight the profound psy- chological impact of AD. The present study also revealed moderate sleep distur- bances due to AD. Lethargy and inability to concentrate are two of the main outcomes of sleep disturbance [27,28], which could explain the low absenteeism but percentages over 50% of work/classroom impairment; Civelek E. and collaborators also reported low school absenteeism in children with AD [29]. In addition, a European retrospective analysis of adult pa- tients with moderate-severe AD showed absenteeism under 5%, although the overall work impairment was around 30% [25], differing from our results. These variations may be due to the higher DLQI values observed in our study. In Europe, moderate-to-severe forms of AD are estimated to cost €30 billion annually [30]. Treatments, dermatology consultations, and hospitalizations are considered the ma- jor economic burden [31,32]. Unfortunately, we could not estimate the financial charges due to AD, although our data indicate that the main burden of this disease falls on derma- tology and primary care, and on patients in terms of the high costs they bear. Despite the severe symptoms experienced by patients with AD and the considerable impact on their lives, we observed Table 5. Impact of AD on Work Productivity and Sleep Disturbances Evaluated by the WPAI and a VAS, respectively. Study parameter Value Patients currently employed, n (%) [N] 42 (68.9) [61] Work productivity, median (IQR) [N] % work time missed due to AD (absenteeism) 0.0 (0.0-9.1) [35] % impairment while working due to AD (presenteeism) 40.0 (20.0-70.0) [35] % overall work impairment due to AD (absenteeism and presenteeism) 50.0 (21.3-70.0) [31] Patients currently attending academic classes, n (%) [N] 13 (25.0) [52] Academic activity, median (IQR) [N] % class time missed due to AD 0.0 (0.0-20.0) [7] % impairment in the classroom due to AD 60.0 (25.0-70.0) [9] % overall classroom impairment due to AD 76.0 (30.0-79.0) [7] Daily activities, median (IQR) [N] % activity impairment due to AD 55.0 (20.0-77.5) [12] Sleep disturbances score (VAS), mean (SD) [N] 6.0 (3.1) [59] Abbreviations: AD: atopic dermatitis; n: patients with event; N: number of patients with available data; SD: standard deviation; VAS: visual analog scale; WPAI: Work Productivity and Activity Impairment Questionnaire. to travel to receive healthcare assistance, with a median cost of €10 (€4.50–20.00) in the month before the study visit. In addition, during the year before the visit, 35.9% of patients invested €50-200 in acquiring products to better control the disease. Notably, 25% of patients reported hav- ing resorted to alternative therapies or unlicensed products, including homeopathy, emollients, parapharmacy creams and soaps, and natural supplements, among others. Patients spent a median of €120 (€11.30–187.50) on these products. Those patients who were in treatment with emollients at the time of the study visit (or during the previous two weeks; Table 6) spent a mean of €40.10 (€30.5) a month on emollients. Discussion Estimating and understanding the burden of AD can help treatment decision-making as well as support public health policies, prioritize interventions, and allocate resources Original Article | Dermatol Pract Concept. 2025;15(3):5538 7 Table 6. Treatment Patterns. Treatment¥ At study visit (in the two weeks before the visit) n (%), N=54 Received in the past n (%), N=59 Planned (after the visit) n (%), N=60 Topical corticosteroids 44 (81.5) 56 (94.9) 47 (78.3) Daily use 23 (54.8) - 36 (76.6) High potency (in case of daily use) 11 (43.5) - 17 (47.2) Emollients 41 (75.9) 51 (86.4) 53 (88.3) Topical calcineurin inhibitors 15 (27.8) 19 (32.2) 18 (30.0) Tacrolimus 13 (24.1) - 16 (26.7) Pimecrolimus 2 (3.7) - 2 (3.3) Other treatments for AD 14 (25.9) - - Antihistamines 10 (18.5) 29 (49.2) 3 (5.0) Systemic antibiotics 1 (1.9) 8 (13.6) 3 (5.0) Topical antibiotics 2 (3.7) 7 (11.9) - Alternative medicine 1 (1.9) 5 (8.5) 0 (0.0) Systemic corticosteroids 13 (24.1) 32 (54.2) 14 (23.3) Treatment duration (days), mean (SD)* 18.6 (25.2) - - Cycles in the last year, mean (SD) - 2.3 (2.8) - Ciclosporin 6 (11.1) 12 (20.3) 15 (25.0) Treatment duration (months), mean (SD) 11 (7.7) - - Phototherapy 2 (3.7) 9 (15.3) 1 (1.7) Systemic immunosuppressors 1 (1.9) 6 (10.2) 2 (3.3) Methotrexate 1 (1.9) 4 (6.8) 2 (3.3) Azathioprine 0 (0.0) 2 (3.4) 0 (0.0) Antiviral - 2 (3.4) 0 (0.0) Dupilumab 0 (0.0) 1 (1.7) 6 (10.0) Abbreviations: AD: atopic dermatitis; n: patients with event; N: number of patients with available data; SD: standard deviation. ¥Multiple response. Percentages can add up to more than 100%. *N=11. a relatively low use of systemic therapies in this population, likely attributable to patients attending a specialized center for the first time (as per established selection criteria). Sys- temic corticosteroids were prescribed in less than 25% of patients, a very similar proportion to that observed by Klein and colleagues [25]. Furthermore, dupilumab was only rec- ommended to six patients after the study visit, despite its approval for moderate-to-severe AD in Spain in 2017. Treat- ment patterns in the Greek and Portuguese cohorts further support a historical reliance on topical therapies, which may now be evolving towards a more disease-specific approach [22,23]. In the present study, although the high use of emol- lients illustrated an attempt to better control the disease and prevent flare-ups, the overall treatment algorithm suggested suboptimal management of AD. Indeed, the use of alterna- tive therapies or unlicensed products by 25% of patients, together with their associated costs, may reflect unmet treat- ment needs. Limitations of this study include missing information on some variables due to the descriptive study nature. As the sample size was low, extrapolating the results might be challenging, although it effectively reflects the Spanish popu- lation with moderate-to-severe AD. Moreover, we could not include enough young patients (data not shown) and ade- quately contrast the data from this specific population. Conclusions Despite its limitations, the APOLO study provides insight into the characteristics and symptoms of a representative moderate-to-severe AD population. This study highlights the devastating impact of AD on patients’ lives in a real-world scenario, with a significant effect on their HR-QoL, sleep disruptions, and work impairments, and the overwhelm- ing financial burden on patients and the Spanish health- care system. 8 Original Article | Dermatol Pract Concept. 2025;15(3):5538 3. Laughter MR, Maymone MBC, Mashayekhi S, et al. The global burden of atopic dermatitis: lessons from the Global Burden of Disease Study 1990-2017. Br J Dermatol. Feb 2021;184(2): 304-309. DOI:10.1111/bjd.19580 PMID: 33006135 4. Escarrer J, Guerra Pérez M. Dermatitis atópica. Protoc diagn ter pediatr. 2019;2:161-75. 5. Silverberg JI, Gelfand JM, Margolis DJ, et al. Patient burden and quality of life in atopic dermatitis in US adults: A population-based cross-sectional study. Ann Allergy Asthma Immunol. Sep 2018;121(3):340-347. DOI:10.1016/j.anai.2018.07.006 PMID: 30025911 6. Carroll CL, Balkrishnan R, Feldman SR, Fleischer AB, Jr., Manuel JC. The burden of atopic dermatitis: impact on the patient, family, and society. Pediatr Dermatol. May-Jun 2005;22(3):192-9. DOI:10.1111/j.1525-1470.2005.22303.x PMID: 15916563 7. Drucker AM, Wang AR, Li WQ, Sevetson E, Block JK, Qureshi AA. The Burden of Atopic Dermatitis: Summary of a Report for the National Eczema Association. J Invest Dermatol. Jan 2017;137(1): 26-30. DOI:10.1016/j.jid.2016.07.012 PMID: 27616422 8. Xu X, van Galen LS, Koh MJA, et al. Factors influencing qual- ity of life in children with atopic dermatitis and their caregiv- ers: a cross-sectional study. Sci Rep. Nov 5 2019;9(1):15990. DOI:10.1038/s41598-019-51129-5 PMID: 31690745 9. Simpson E, Bissonnette R, Eichenfield LF, et al. The Validated In- vestigator Global Assessment for Atopic Dermatitis (vIGA-AD): The development and reliability testing of a novel clinical outcome measurement instrument for the severity of atopic dermatitis. J Am Acad Dermatol. Sep 2020;83(3):839-846. DOI:10.1016/j.jaad.2020.04.104 PMID: 32344071 10. Finlay AY, Khan GK. Dermatology Life Quality Index (DLQI)--a simple practical measure for routine clinical use. Clin Exp Der- matol. May 1994;19(3):210-6. DOI:10.1111/j.1365-2230.1994. tb01167.x PMID: 8033378 11. EuroQol G. EuroQol--a new facility for the measurement of health-related quality of life. Health Policy. Dec 1990;16(3): 199-208. DOI:10.1016/0168-8510(90)90421-9 PMID: 10109801 12. Lewis-Jones MS, Finlay AY. The Children’s Der- matology Life Quality Index (CDLQI): initial Ethics Approval: This study was approved by the Ethics Committee of the Hospital General Universitario Gregorio Marañón (Madrid, Spain). The study was conducted in ac- cordance with the ethical principles of the Declaration of Helsinki, Good Clinical Practice (GCP), and in compliance with European and local requirements. Written informed consent was obtained from all patients (or their legal guard- ians) before their inclusion. Funding: This work was supported by Pfizer S.L.U. Acknowledgments: Scientific advisory and medical writing assistance were provided by Carla Martín Cortázar from Ev- idenze Health España S.L.U. during the preparation of this manuscript, according to Good Publication Practice guide- lines. The responsibility for opinions, conclusions, and inter- pretation of data lies with the authors. Data Availability: All data generated during this study are available from the corresponding author upon reasonable request. References 1. Barbarot S, Auziere S, Gadkari A, et al. Epidemiology of atopic dermatitis in adults: Results from an international survey. Allergy. Jun 2018;73(6):1284-1293. DOI:10.1111/all.13401 PMID: 29319189 2. Silverberg JI, Barbarot S, Gadkari A, et al. Atopic dermatitis in the pediatric population: A cross-sectional, international epidemiologic study. Ann Allergy Asthma Immunol. Apr 2021;126(4):417-428 e2. DOI:10.1016/j.anai.2020.12.020 PMID: 33421555 Figure 1. Healthcare departments most frequently visited by patients with AD Original Article | Dermatol Pract Concept. 2025;15(3):5538 9 23. Stratigos AJ, Chasapi V, Katoulis A, et al. Unveiling the Impact of Moderate and Severe Atopic Dermatitis: Insights on Burden, Clin- ical Characteristics, and Healthcare Resource Utilization in Adult Greek Patients from the APOLO Cross-Sectional Study. J Clin Med. Oct 23 2024;13(21)DOI:10.3390/jcm13216327 PMID: 39518471 24. Fasseeh AN, Elezbawy B, Korra N, et al. Burden of Atopic Dermatitis in Adults and Adolescents: a Systematic Literature Review. Dermatol Ther (Heidelb). Dec 2022;12(12):2653-2668. DOI:10.1007/s13555-022-00819-6 PMID: 36197589 25. Kleyn CE, Barbarot S, Reed C, et al. Burden of Moderate to Severe Atopic Dermatitis in Adults from France, Italy, and the UK: Patient-Reported Outcomes and Treatment Patterns. Der- matol Ther (Heidelb). Aug 2022;12(8):1947-1965. DOI:10.1007 /s13555-022-00777-z PMID: PMID: 35913548 26. Ohya Y, Saeki H, Nawata H, et al. The disease burden of pedi- atric patients with atopic dermatitis in Japan. Pediatr Dermatol. Sep-Oct 2023;40(5):851-856. DOI:10.1111/pde.15399 PMID: 37581214 27. Bender BG, Leung DY. Sleep disorders in patients with asthma, atopic dermatitis, and allergic rhinitis. J Allergy Clin Immu- nol. Dec 2005;116(6):1200-1. DOI:10.1016/j.jaci.2005.09.041 PMID: 16337445 28. Yu SH, Attarian H, Zee P, Silverberg JI. Burden of Sleep and Fa- tigue in US Adults With Atopic Dermatitis. Dermatitis. Mar-Apr 2016;27(2):50-8. DOI:10.1097/DER.0000000000000161 PMID: 26983091 29. Civelek E, Sahiner UM, Yuksel H, et al. Prevalence, burden, and risk factors of atopic eczema in schoolchildren aged 10-11 years: a national multicenter study. J Investig Allergol Clin Immunol. 2011;21(4):270-7 PMID: 21721372 30. Augustin M, Misery L, von Kobyletzki L, Armario-Hita JC, Mealing S, Redding M. Unveiling the true costs and societal im- pacts of moderate-to-severe atopic dermatitis in Europe. J Eur Acad Dermatol Venereol. Jul 2022;36 Suppl 7:3-16. DOI:10.1111 /jdv.18168 PMID: 35801296 31. Mohr N, Naatz M, Zeervi L, et al. Cost-of-illness of atopic dermatitis in Germany: data from dermatology routine care. J Eur Acad Dermatol Venereol. Jun 2021;35(6):1346-1356. DOI:10.1111/jdv.17203 PMID: 33651457 32. Sicras-Mainar A, Navarro-Artieda R, Carrascosa Carrillo JM. Economic Impact of Atopic Dermatitis in Adults: A Population-Based Study (IDEA Study). Actas Dermosifiliogr (Engl Ed). Jan-Feb 2018;109(1):35-46. Impacto economico de la derma- titis atopica en adultos: estudio de base poblacional (estudio IDEA). DOI:10.1016/j.ad.2017.09.003 PMID: 29126499 validation and practical use. Br J Dermatol. Jun 1995;132(6):942- 9. DOI:10.1111/j.1365-2133.1995.tb16953.x PMID: 7662573 13. Reilly MC, Zbrozek AS, Dukes EM. The validity and reproduc- ibility of a work productivity and activity impairment instrument. Pharmacoeconomics. Nov 1993;4(5):353-65. DOI:10.2165 /00019053-199304050-00006 PMID: 10146874 14. Lawson V, Lewis-Jones MS, Finlay AY, Reid P, Owens RG. The family impact of childhood atopic dermatitis: the Dermatitis Family Impact Questionnaire. Br J Dermatol. Jan 1998;138(1):1 07-13. DOI:10.1046/j.1365-2133.1998.02034.x PMID: 9536231 15. Charman CR, Venn AJ, Williams HC. The patient-oriented ec- zema measure: development and initial validation of a new tool for measuring atopic eczema severity from the patients’ perspec- tive. Arch Dermatol. Dec 2004;140(12):1513-9. DOI:10.1001 /archderm.140.12.1513 PMID: 15611432 16. Yosipovitch G, Reaney M, Mastey V, et al. Peak Pruritus Numer- ical Rating Scale: psychometric validation and responder defini- tion for assessing itch in moderate-to-severe atopic dermatitis. Br J Dermatol. Oct 2019;181(4):761-769. DOI:10.1111 /bjd.17744 PMID: 30729499 17. Hanifin JM, Thurston M, Omoto M, Cherill R, Tofte SJ, Graeber M. The eczema area and severity index (EASI): assess- ment of reliability in atopic dermatitis. EASI Evaluator Group. Exp Dermatol. Feb 2001;10(1):11-8. DOI:10.1034/j.1600 -0625.2001.100102.x PMID: 11168575 18. Murray CJ, Lopez AD. Measuring the global burden of dis- ease. N Engl J Med. Aug 1 2013;369(5):448-57. DOI:10.1056/ NEJMra1201534 PMID: PMID: 23902484 19. Beretzky Z, Koszoru K, Rencz F, et al. Societal costs and health related quality of life in adult atopic dermatitis. BMC Health Serv Res. Aug 14 2023;23(1):859. DOI:10.1186/s12913-023- 09840-7 PMID: 37580792 20. Eyerich K, Gooderham MJ, Silvestre JF, et al. Real-world clin- ical, psychosocial and economic burden of atopic dermatitis: Results from a multicountry study. J Eur Acad Dermatol Vene- reol. Feb 2024;38(2):340-353. DOI:10.1111/jdv.19500 PMID: 37669868 21. Sanchez-Perez J, Dauden-Tello E, Mora AM, Lara Surinyac N. Impact of atopic dermatitis on health-related quality of life in Spanish children and adults: the PSEDA study. Actas Dermosi- filiogr. Jan 2013;104(1):44-52. DOI:10.1016/j.ad.2012.03.008 PMID: 22841507 22. Duarte B, Mendes-Bastos P, Antunes J, et al. The APOLO Study: A Cross-Sectional Analysis of Disease Characteristics and Patient Burden in Moderate-to-Severe Atopic Dermatitis in Portugal. Dermatol Ther (Heidelb). Mar 2025;15(3):647-662. DOI:10.1007/s13555-025-01347-9 PMID: 39930312