Atopic dermatitis patients at higher risk of osteoporosis

Absolute risk is low, but it's real -- People with atopic dermatitis (AD) are at a significantly higher risk of osteoporosis and major osteoporotic fractures, according to a recent study. This risk remains true even if they've never taken systemic corticosteroids, in fact, these elevated risks were concentrated in the patients who used potent or superpotent topical corticosteroids. Adult Atopic dermatitis patients who used mild- or moderate-potency topical steroids were not at significantly increased risk.

Atopic Dermatitis or Eczema is a chronic inflammation of the skin characterized by itchy and red skin. It affects up to 25% of children, and an estimated 60% of people with eczema develop it during their first year of life.

The findings were reported at a meeting of the European Task Force on Atopic Dermatitis held in conjunction with the annual congress of the European Academy of Dermatology and Venereology. The study was presented by Jacob P. Thyssen, professor of dermatology at the University of Copenhagen.

"Dermatologists should consider alternative treatments in the chronic excessive users of topical corticosteroids, or use them in combination with prophylactic treatment to preserve bone homeostasis in such patients," he advised the fellow dermatologists.

The study is a retrospective case-control study of 10,636 Danish adults with AD and 87,989 matched controls. At baseline in this study participants had no history of osteoporosis and it featured a maximum of 20 years of follow-up starting in 1997.

Dr. Thyssen expressed the absolute risk of being diagnosed with osteoporosis in the study as follows: If 10,000 adult AD patients were followed for 1 year, on average 23.5 of them would be diagnosed with osteoporosis, a rate more than double the 10.3 per 10,000 in the general population. Moreover, on average, 42.6 out of 10,000 adult AD patients would incur a major osteoporotic fracture during a year of follow-up, compared with 32.3 individuals in the general population.

Read Also: Eczema patients at increased risk of osteoporotic fractures, finds study

Key findings of the study include:

• In the subgroup of patients who never used systemic corticosteroids, the risk of being diagnosed with osteoporosis was 12.8 per 10,000 per year, significantly higher than the 7.4 per 10,000 rate in the general population.


• The 1-year rate of major osteoporotic fractures was 33.1 per 10,000 among the AD group and 29.6 in matched controls.


• In a Cox regression analysis adjusted for age, sex, socioeconomic status, body mass index, asthma, and the use of a variety of medications thought to potentially have a negative effect upon bone metabolism, the risk of osteoporosis in the entire group of 10,636 adult AD patients was 51% greater than in matched controls, and their risk of major osteoporotic fractures was 18% greater.


• In the subgroup of AD patients who never used systemic steroids, the risks of osteoporosis and major osteoporotic fractures were 82% and 14% greater than in controls.


• The medications adjusted for in the regression analysis included proton pump inhibitors, thiazide diuretics, H₂ receptor blockers, statins, cyclosporine, hormone therapy, contraceptives, and psychotropic medications.


• Scoring Atopic Dermatitis (SCORAD) ratings were available on roughly 4,000 of the adult AD patients. In an analysis of this large subgroup, disease severity as reflected in SCORAD scores did not explain the increased osteoporosis and fracture risks. However, the use of potent or superpotent topical corticosteroids did.


• Patients who used potent topical steroids had a statistically significant 16% increased risk of being diagnosed with osteoporosis than nonusers, as well as a 7% increased risk of major osteoporotic fractures.


• Patients who applied superpotent topical steroids had 42% and 18% increased risks of those two adverse outcomes.


• Neither the use of topical calcineurin inhibitors nor mild- or mid-potency topical steroids was associated with increased risk of bone events in a Cox regression analysis adjusted for potential confounders.

According to Dr. Thyssen, A relationship between the use of high-potency topical corticosteroids and adverse bone events is biologically plausible. "We find it very likely that, if you put topical steroids on atopic skin in high amounts and for a very long time, you may have systemic effects," he said.

A great many adult AD patients do exactly that. When Dr. Thyssen and coworkers analyzed Danish national prescription drug registry data for their patient cohort, they found that roughly one-third of the elderly subgroup had filled prescriptions totaling greater than 2 kg of mometasone or other similar-potency steroids over the previous 10 years.

"So we know that a significant proportion of our atopic dermatitis patients are really high users of topical corticosteroids," the dermatologist noted.