Severe Itch and Skin Lesions Linked to Higher Health Care Costs in Atopic Dermatitis

Key Clinical Summary

• A real-world US study of 4433 patients with moderate-to-severe atopic dermatitis (AD) found that both itch intensity and skin lesion severity were associated with increased health care charges.
• Patients with severe itch and severe lesions incurred the highest mean annual health care charges ($34 145), compared with $23 697 among patients with moderate itch and moderate lesions.
• Severe itch was associated primarily with higher pharmacy expenditures, while severe lesions contributed to greater outpatient costs, highlighting the potential value of incorporating both symptom measures into disease management.

Patients with moderate-to-severe AD who experienced both severe itch and severe skin lesions incurred substantially higher annual health care charges than those with less severe symptoms, according to a real-world US study. The findings suggest that evaluating both patient-reported itch intensity and clinician-assessed lesion severity may help identify patients with greater health care needs and inform more individualized treatment strategies.

The retrospective analysis, published in Dermatology and Therapy, examined how different combinations of itch and lesion severity were associated with health care resource utilization and expenditures. Researchers found that the combined burden of severe itch and severe lesions was associated with the highest overall charges, primarily driven by pharmacy and outpatient services.

Four Clinical Phenotypes Reveal Differences in Economic Burden

Researchers analyzed linked electronic health records and claims data from the OMNY Health Dermatology Platform between January 2022 and June 2024.

The study included 4433 patients aged 12 years or older with moderate-to-severe AD, identified according to prescription treatment history.

Patients were classified into 4 clinical phenotypes using the Itch Numerical Rating Scale (NRS) and Investigator Global Assessment (IGA). Approximately 33% had moderate itch and moderate lesions, 43% had severe itch and moderate lesions, 4% had moderate itch and severe lesions, and 21% had severe itch and severe lesions.

Investigators used multinomial propensity score weighting to evaluate annualized all-cause health care resource utilization and gross charges across the groups.

The severe itch and moderate lesions phenotype was the most common, accounting for 43% of patients. This finding highlights the importance of assessing itch independently of visible skin involvement when evaluating AD severity.

Annual Health Care Charges Highest With Combined Severe Symptoms

Mean annual health care charges increased as itch and lesion severity worsened.

Patients with moderate itch and moderate lesions incurred the lowest mean annual charges at $23 697, followed by $25 894 among those with severe itch and moderate lesions and $27 402 among those with moderate itch and severe lesions. Patients experiencing both severe itch and severe lesions incurred the highest annual charges at $34 145.

Compared with patients with moderate itch and moderate lesions, those with severe itch alone incurred an additional $2197 in annual charges, while those with severe lesions alone incurred an additional $3705.

Patients with both severe itch and severe lesions had the greatest economic burden, with annual charges $10 448 higher than those in the moderate itch and moderate lesions group.

The researchers identified differences in the types of expenditures associated with each symptom domain. Severe itch was primarily associated with increased pharmacy charges, whereas severe lesions were associated with greater outpatient spending.

Among patients with both severe itch and severe lesions, mean annual outpatient charges reached $9555, compared with $1620 to $4071 across the other phenotypes.

Pharmacy charges were also substantial, reaching $22 955 among patients with both severe itch and severe lesions.

These findings suggest that itch and lesion severity contribute differently to the economic burden of AD, potentially reflecting variations in treatment needs and health care utilization.

Health Care Utilization Similar Despite Differences in Charges

Although total health care charges differed substantially across phenotypes, hospitalization and emergency department utilization were generally similar.

The proportion of patients experiencing at least 1 hospitalization ranged from 2.7% among those with severe itch and moderate lesions to 4.4% among those with severe itch and severe lesions.

Approximately 20% to 26% of patients across phenotypes experienced at least 1 emergency department visit.

Outpatient visits were also relatively common, with approximately 30% of patients receiving outpatient care during follow-up. Adjusted mean outpatient visits ranged from 1.3 to 1.8 per patient annually across the full study population.

However, among patients who utilized outpatient services, the mean number of visits ranged from 4.7 to 5.8 annually.

The findings indicate that differences in health care charges were not necessarily driven by substantially higher rates of acute care utilization. Instead, outpatient and pharmacy expenditures accounted for much of the variation in total charges.

Treatment Patterns and Comorbidities Influence Economic Burden

Treatment histories differed across clinical phenotypes, with patients experiencing more severe symptoms generally demonstrating greater use of systemic therapies.

More than 90% of patients had previously received topical corticosteroids, while fewer than 2% had received phototherapy.

Systemic immunomodulator use increased from 24% among patients with moderate itch and moderate lesions to 44% among those with severe itch and severe lesions.

Similarly, systemic corticosteroid use ranged from 62% in the least severe phenotype to 72% in the most severe phenotype.

Comorbidities were also common. Across the study population, 40% had a history of depression or anxiety, 33% had chronic pulmonary disease, 30% had allergic rhinitis, and 29% had sleep disorders.

Patients with both severe itch and severe lesions had the highest prevalence of chronic pulmonary disease (36%) and at least 1 additional atopic condition (47%).

In multivariable analyses, several factors were associated with health care charges at or above the 90th percentile.

Recent biologic treatment was associated with approximately twice the odds of high total charges (odds ratio, 2.08; 95% CI, 1.63-2.65). Systemic corticosteroids, systemic immunomodulators, opioid use, and comorbidities were also associated with increased charges.

The authors noted that higher charges among patients receiving biologic therapies may reflect both medication costs and the greater treatment needs of patients with more severe disease.

Implications for Managed Care

The findings highlight the potential value of incorporating both patient-reported symptoms and clinician-assessed disease severity into AD management strategies.

Traditional assessments often emphasize visible skin lesions. However, the study found that patients with severe itch but moderate lesions represented the largest clinical phenotype and incurred higher pharmacy charges than patients with moderate itch and moderate lesions.

For managed care organizations, these findings suggest that lesion severity alone may not fully capture the clinical and economic burden of AD.

Including patient-reported itch assessments alongside clinician-reported measures could help identify patients with persistent symptoms who may require treatment reassessment or additional support.

The findings also demonstrate that higher health care charges can occur without substantial differences in hospitalization or emergency department utilization, emphasizing the importance of evaluating outpatient and pharmacy expenditures when assessing disease burden.

However, the study measured gross health care charges rather than actual payments or net costs to insurers. Therefore, the reported amounts should not be interpreted as direct payer expenditures.

Additionally, the retrospective observational design cannot establish that severe itch or lesions caused higher spending. Differences in baseline characteristics, treatment patterns, and comorbidities may have contributed to the observed associations.

Further longitudinal research is needed to determine whether phenotype-informed treatment strategies can improve disease control, reduce health care utilization, or lower costs.

Conclusion

In this real-world US analysis, both itch intensity and skin lesion severity were associated with increased health care charges among patients with moderate-to-severe AD.

Patients experiencing both severe itch and severe lesions incurred the highest annual charges, while the distinct associations between itch, pharmacy spending, and outpatient utilization suggest that both symptom domains are important considerations in evaluating disease burden.

The findings support a more comprehensive approach to AD assessment that integrates patient-reported itch severity with clinician-assessed skin involvement to inform individualized disease management and managed care decision-making.

Reference

Zirwas M, Lio P, Rasouliyan L, et al. Healthcare resource utilization and economic burden across clinical phenotypes of moderate-to-severe atopic dermatitis in United States dermatology facilities. Dermatol Ther (Heidelb). 2026;16:437–450. doi:10.1007/s13555-025-01590-0