Dermatol Ther (Heidelb) (2021) 11:161–172
https://doi.org/10.1007/s13555-020-00470-z
ORIGINAL RESEARCH
Clinical and Economic Burden of Pediatric Mild-toModerate Atopic Dermatitis: A Population-Based
Nested Case–Control Study in Sweden
Gustaf Ortsäter
. Kirk Geale . Alexander Rieem Dun .
Joseph C. Cappelleri . Amy Cha . William Romero . Dan Henrohn .
Petra Neregard . Maureen P. Neary
Received: October 9, 2020 / Accepted: November 21, 2020 / Published online: December 18, 2020
Ó The Author(s) 2020
ABSTRACT
Introduction: Atopic dermatitis (AD) is a
chronic, relapsing inflammatory skin condition
characterized by pruritic, eczematous lesions.
Recent evidence suggests that AD may be a
systemic disorder, implying that management
Supplementary Information The online version
contains supplementary material available at https://
doi.org/10.1007/s13555-020-00470-z.
G. Ortsäter (&) K. Geale A. R. Dun
Quantify Research AB, Stockholm, Sweden
e-mail: gustaf.ortsater@quantifyresearch.com
K. Geale
Dermatology, Department of Public Health and
Clinical Medicine, Umeå University, Umeå, Sweden
J. C. Cappelleri
Global Biometrics and Data Management
(Statistics), Pfizer Inc, Groton, CT, USA
A. Cha
Inflammation and Immunology, Pfizer Inc, New
York, NY, USA
W. Romero
Inflammation and Immunology, Pfizer Ltd, London,
UK
D. Henrohn P. Neregard
Inflammation and Immunology, Pfizer AB,
Stockholm, Sweden
M. P. Neary
Inflammation and Immunology, Pfizer Inc,
Collegeville, PA, USA
of this disease extends beyond merely controlling symptoms associated with AD. Even
though this disease is highly prevalent in children and patients typically present with mildto-moderate symptoms, the disease burden is
not well established.
Methods: A large, retrospective cohort study of
Swedish population data was conducted to
compare the clinical burden in terms of
healthcare resource use and direct medical costs
for pediatric mild-to-moderate (pM2M) AD
patients (B 14 years of age, N = 87,721) with
matched controls. The burden of a severe AD
cohort was also evaluated. Severity of AD was
defined by treatment usage and systemic treatment was used as a proxy for severe AD. A
robust approach was used by including any type
of secondary care visits known to be more
common in AD patients than in the general
population; however, data for primary care visits were not available.
Results: For healthcare resource use, the incidence rate ratio (pM2M AD versus reference
cohort) of secondary care visits ranged from
1.56 to 2.35 during each of 5 years after AD
onset (all p \ 0.001), with largest differences
seen in years 1–2. The average direct medical
cost (SD) was €1111 (3416) and €524 (2446) in
the pM2M AD and reference cohorts, respectively. The corresponding estimate in the severe
AD cohort was €1906 (7067). Including all secondary care visits and pharmacy-dispensed
medications, the pM2M AD cohort was shown
162
to have an additional €118.9 million in direct
medical costs over 5 years compared with the
reference cohort.
Conclusions: This study shows significant
clinical and economic burden of pM2M AD
with important secondary care resource utilization, suggesting a need for further research to
increase treatment options and improve the
management of these patients.
Keywords: Atopic dermatitis; Epidemiology;
Public health research; Pediatrics
Key Summary Points
Why carry out this study?
Even though atopic dermatitis is highly
prevalent in children and patients
typically present with mild-to-moderate
symptoms, the disease burden is not well
established.
This study compared the clinical and
economic burden for pediatric mild-tomoderate patients with atopic dermatitis.
What was learned from the study?
Total direct medical costs for pediatric
patients with mild-to-moderate atopic
dermatitis in Sweden are €118.9 million
higher, cumulatively after 5 years, than in
individuals without the disease.
Pediatric mild-to-moderate patients incur
substantial clinical and economic burden
in secondary care.
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Dermatol Ther (Heidelb) (2021) 11:161–172
INTRODUCTION
Atopic dermatitis (AD) is a chronic, relapsing
inflammatory skin condition which manifests
as pruritus and eczematous lesions that can be
acute, subacute, or chronic [1, 2]. Prevalence of
AD is high across all continents, and approximately 20% of children and 2–8% of adults are
affected in Western countries [2, 3]. Prevalence
appears to be increasing in Western Europe
[2, 4] and seems stable in Northern Europe [5].
In roughly 60% of cases, AD manifests during
the first year of life (i.e., early onset), but it may
start at any age [6, 7].
Evidence increasingly suggests that AD may
be a systemic disorder with common inflammatory mechanisms underlying certain comorbid conditions, contributing to the patient and
economic burden of AD [8]. The disease is
associated with a wide range of non-allergic
comorbid disorders including anxiety, depression, suicidality, attention deficit hyperactivity
disorder, and infections [9–12]. Atopic dermatitis is also often considered to be the first
clinical manifestation in the ‘‘atopic march’’
which links the disease to subsequent food
allergy, rhinitis, and asthma [11, 13]. This
means that the true burden of atopic dermatitis
may extend well beyond the strictly dermatological spectrum.
Most AD patients have mild-to-moderate
disease, whereas approximately 10% of patients
suffer from severe disease [2]. Although disease
burden increases with severity [14–16], mild-tomoderate AD is also associated with substantial
patient and economic burden [17]. Evidence
regarding the burden of AD is, however, scarce
for mild-to-moderate patients. While a recent
systematic review of patient impact and economic burden of mild-to-moderate AD concluded that even mild AD imposed substantial
costs and impacted on patient’s health-related
quality of life, only two studies were European,
and the most recent study was published in
2006 [18–20]. Neither of these studies included
a control cohort, and they were limited by
sample sizes (range 33–474) and follow-up
duration (range 3 months–8 years). In another
systematic review of economic evidence for
Dermatol Ther (Heidelb) (2021) 11:161–172
prevention and treatment of atopic eczema,
four additional European studies were identified, but none included stratification by severity
[21].
The high prevalence of mild-to-moderate
AD, particularly in children, may lead to a high
potential for economic burden through health
care contacts and prescribed medications. To
improve the understanding of the clinical and
economic burden for pediatric patients with
mild-to-moderate (pM2M) AD, the present
study evaluates the clinical burden in terms of
healthcare resource use for AD and the direct
medical cost burden over time at the secondary
care level. The current study adds to the existing
literature by focusing on pediatric mild-tomoderate patients. It also combines complete,
nationwide registry data with a long follow-up
period and a cohort of reference individuals.
METHODS
Data and Ethics
Two population-based Swedish registries, the
National Patient Register (NPR), and the Prescribed Drug Register (PDR) were used in this
study. Both registers are governed by the
Swedish National Board of Health and Welfare
and use a common and unique identification
number for each individual, enabling patientlevel linkage between registries. The data used
in this study were anonymized. This implied
that the granularity of certain variables was
limited to ensure the anonymity of the patient.
Specifically, this meant that the date of secondary care visits and dispensation was provided on a yearly level, age was available in age
groups of five (0–4, 5–9, etc.) and Anatomical
Therapeutic Chemical (ATC) codes were truncated to a three-digit level.
The NPR contains information on all secondary care (care visits, either outpatient visit
or inpatient hospitalization with referral from
primary care) in Sweden and data for year of
visit, gender, age, and main diagnosis (atopic
dermatitis or other diagnosis) were collected for
each study participant between 1 January 2001
and 31 December 2017. The PDR contains
163
information on all drug dispensations (originating from both primary and secondary care)
filled at pharmacies in Sweden. Data for the
ATC code (truncated to three digits), the year of
dispensation, and cost of the dispensation for
each study participant between 1 July 2005 and
31 December 2017 was collected from the PDR.
The cost of dispensed drugs was extracted
directly from the PDR which contains the publicly available list prices. All types of dispensed
drugs were included in the calculation of total
direct medical costs. Cost of drugs was inflated
to the 2018 price level using the Swedish consumer price index and then converted into
euros using the average exchange rate of SEK/€
during 2018 (€1 = 10.31 SEK). Unit costs of
secondary care visits (differentiated between AD
visit and non-AD visit) were extracted from
several Swedish regional price lists [22–28] to
ensure accurate prices which may vary across
regions.
This study was approved by the Regional
Ethical Review Board in Gothenburg (Dnr:
2019-02986) and performed in accordance with
the ethical standards in the 1964 Declaration of
Helsinki and its later amendments. For this type
of study, individual formal consent was not
required.
Study Population
This was a retrospective, observational nested
case–control study including children aged
0–14 (inclusive) in Sweden with either a primary diagnosis of AD (ICD-10 code L20? or
L30.8C) in secondary care, or by dispensation of
two (within 12 months of each other) topical
corticosteroids (TCS), or a topical calcineurin
inhibitor (TCI) between 1 January 2009 and 31
December 2017. A schematic outline of the
study design is provided in Fig. 1. Patients
identified through a dispensation (TCS or TCI)
were identified from the PDR which contains all
dispensations for primary and secondary care.
Hence, patients could be included either
through diagnosis code (using the International
Classification of Diseases, ICD-10) in secondary
care and/or a drug dispensation originating
from secondary or primary care. Treatment with
Dermatol Ther (Heidelb) (2021) 11:161–172
164
Wash-out period
July 1, 2005
January 1, 2009
Idenficaon period of index event
(Dispensing of two topical corcosteroids within 12 months,
dispensaon of a topical calcineurin inhibitor,
or an AD diagnosis in secondary care)
Dec 31, 2017
HRU and associated
cost collected annually during follow-up
period (Five years or unl
end of study period)
Baseline
period
(index-year)
Index
date
Study period
Fig. 1 Study design
TCS drugs is indicated for several skin conditions (including other types of dermatitis and
psoriasis), and TCS dispensation alone is a poor
predictor of AD diagnosis [29]. Therefore, subjects with hospital visits related to other types of
dermatitis or medical conditions known to lead
to the use of TCS were excluded from the study
population. Diagnosis codes which required
exclusion are listed in Table S.I in the supplementary material. In addition to excluding
patient-based diagnosis codes to further refine
the study population, patients with dispensations of TCSs used in other types of dermatitis
or to treat vaginal fungal infection, antipsoriatics or salicylates for dermatological use were
also excluded from the study population. ATC
codes which required exclusion are listed in
Table S.II. The exclusion algorithm used in this
study was based on a previously published study
in Sweden [5]. This study used the European
classification system for the potency of corticosteroids which includes four levels (I–IV) in
ascending order of potency [30].
As severity of the disease is not coded in
administrative registers, this study defined
severity based on concurrent treatment
employed in a previously published study [31].
Patients with systemic treatments (corticosteroids and non-corticosteroid immunosuppressants) were considered to have a severe form
of AD and are presented separately in this publication for reference [31].
The pM2M AD cohort was matched by age
and gender to a random sample (reference
cohort) from the Total Population Register held
by Statistics Sweden. The register covers the
entire Swedish population from 1968 and contains basic demographic and socioeconomic
information on the individual level. In this
study, the register was only used to identify the
reference cohort and no information was
extracted. The two cohorts (the pM2M AD and
reference cohort) were mutually exclusive and
had equal lengths of follow-up.
Study Design
The date of inclusion was selected as the
patient’s index date and is a proxy for the start
of clinically diagnosed AD or a new episode
with AD-care visits and/or treatment (after a
look-back period of at least 3.5 years without
treatment in primary or secondary care and/or a
secondary care visit due to AD). Patients were
followed from index date until the end of study
period on 31 December 2017. Date of death was
not available in this study and thus not controlled for. Each reference individual was allocated the same index date as their matched
case. This implied that each case and
Dermatol Ther (Heidelb) (2021) 11:161–172
corresponding reference had identical followup. Demographic characteristics and treatment
type (case cohort) were described at the index
date.
Statistical Analyses
Healthcare resource use was observed annually
from index date until the end of the study
period. All secondary care visits (AD- and nonAD-related) were included, and the incidence
rate ratio (IRR) of secondary care visits between
the pM2M AD cohort and reference cohort was
calculated annually by dividing the number of
secondary care visits per year in the pM2M AD
cohort by the number in the reference cohort.
Total direct medical costs, including cost of all
AD-related and non-AD-related secondary care
visits and dispensed drugs were calculated
annually in all cohorts. The cost of secondary
care visits was calculated by multiplying each
secondary care visit by one of the following
costs: €275 per AD-related outpatient visit, €279
per non-AD-related outpatient visit, €546 per
day of AD-related inpatient hospitalization, and
€661 per day of non-AD-related inpatient hospitalization. A visit was considered AD-related if
the primary diagnosis was either L20? or
L30.8C. Cost of dispensed drugs was extracted
directly from the PDR.
The number (n), mean, and standard deviation (SD) were presented for continuous variables while the number and percentage were
presented for categorical variables. Comparisons between the pM2M AD and the reference
cohort were evaluated using statistical tests with
an a priori significance level of alpha = 0.05. An
independent two-group t test was used to compare means for continuous variables, and a chisquare test to compare proportions for categorical variables [32]. Statistical comparisons were
made within years between patients and reference individuals, but comparisons across years
were not performed. All analyses were performed in Stata (StataCorp. 2019. Release 16.
College Station, TX, USA: StataCorp LLC.).
165
RESULTS
Patient Characteristics and Clinical Burden
A total of 99,300 patients were included in the
two case cohorts through a secondary care
diagnosis of AD, a TCS dispensation, and/or a
TCI dispensation according to previously used
criteria [5]. Of these, 11.7% (11,609) received
systemic treatments during the study period
and were deemed to have severe AD. The
remaining 87,721 patients were considered to
have mild-to-moderate AD. An equal number
(87,721) of reference individuals were included
in the reference cohort.
Baseline characteristics for the mild-to-moderate cohort, the severe AD cohort, and the
reference cohort at index date are presented in
Table 1. At index date, 67.5% of pM2M were
between 0 and 4 years old, and 53.2% were
male. In the severe subgroup, patients were
older, and 57.6% were male. A majority of AD
patients were identified through a TCS dispensation, 89.1% and 89.7% in the pM2M and
severe AD cohort, respectively.
Healthcare Resource Use
The pM2M AD cohort had a larger number of
secondary care visits (for any reason) on average
than the reference cohort during all years of
follow-up. In the index year, the average number (SD) of all secondary care visits was 2.25
(3.36) and 0.96 (2.14) per patient in the pM2M
AD and reference cohort, respectively (Fig. 2).
Most secondary care visits were outpatient visits
(94.5%), while hospitalizations were uncommon (5.5%). The severe AD cohort had on
average 3.14 (6.16) secondary care visits in the
index year. The largest IRR between the pM2M
AD cohort and the reference cohort was found
in the first two years (2.35 and 1.91, respectively) following index and ranged between
1.56 and 2.35 (P \ 0.001) for up to 1–5 years
after disease onset. Similarly, the average number of drug dispensations (any drug) was also
larger in the pM2M AD cohort compared with
the reference cohort throughout the follow-up.
During the index year, the pM2M AD cohort
Dermatol Ther (Heidelb) (2021) 11:161–172
166
Table 1 Patient characteristics at index date
Pediatric mild-to-moderate cohort
Pediatric severe cohort
Reference cohort
87,721
11,609
87,721
0–4
59,192 (67.5%)
6556 (56.5%)
59,192 (67.5%)
5–9
17,469 (19.9%)
2836 (24.4%)
17,469 (19.9%)
10–14
11,060 (12.6%)
2217 (19.1%)
11,060 (12.6%)
Female
41,036 (46.8%)
4922 (42.4%)
41,036 (46.8%)
Male
46,685 (53.2%)
6687 (57.6%)
46,685 (53.2%)
78,122 (89.1%)
10,416 (89.7%)
1758 (2.0%)
318 (2.7%)
9056 (10.3%)
1106 (9.5%)
Number of unique patients
Age group
Gender
Treatment type at index datea
TCSb
TCIc
No treatment
a
b
c
d
d
Number of patients may exceed number of unique patients since one patient may use TCS and TCI concomitantly
Topical corticosteroid
Topical calcineurin inhibitor
Patients were followed from first diagnosis in secondary care
received on average 12.50 pharmacy dispensations per patient while reference individuals on
average received 3.39 pharmacy dispensations
per patient (data not shown). Patients in the
severe AD cohort received on average 17.90
dispensations in the index year. The mean difference in healthcare resource use (both in
terms of secondary care visits and dispensed
drugs) between the pM2M AD and the reference
cohort was statistically significant (P \ 0.001) in
all years. Detailed statistics are reported in
Table S.III in the supplementary material
section.
Direct Medical Costs
Given the larger healthcare resource use in the
pM2M AD cohort, direct medical costs were
consequently also larger in the pM2M AD
cohort compared with the reference cohort.
During the index year, the average direct medical costs were €587 higher per patient in the
pM2M AD cohort compared with that for
patients in the reference cohort. The average
direct medical cost (SD) in the pM2M AD cohort
was €1111 (3416), and €524 (2446) in the reference cohort. The corresponding estimate in
the severe AD cohort was €1906 (7067). The cost
of secondary care visits for patients in the
pM2M AD cohort (€428 per patient) represented
73% of the incremental direct medical costs,
while the cost of dispensed drugs (€159 per
patient) represented the remaining 27%. Five
years following index date, the cumulative difference in total direct medical costs was €118.9
million (€1663 per patient) for the entire pM2M
cohort. Detailed statistics are reported in
Table S.IV in the supplementary material
section.
DISCUSSION
This large, retrospective, observational study
identified a significant clinical and economic
burden in patients with mild-to-moderate AD
Dermatol Ther (Heidelb) (2021) 11:161–172
167
Fig. 2 Average number of yearly secondary care visits per patient (AD- and non-AD-related), by year after index. The error
bars represent 95% confidence intervals
treated at the secondary care level. Economically, direct medical costs were €1663 higher per
patient over 5 years. At a population level in
Sweden, a country with 10 million inhabitants,
this translates to an aggregate (excess) societal
economic burden of €118.9 million. Given the
high prevalence of AD worldwide, this study
provides important data on the clinical and
economic burden of this common skin disease
[5, 18, 33].
A decline in secondary healthcare resource
use following index date was observed in the
present study and may indicate that patients’
symptoms improved over time, potentially
through successful treatment regimens or
spontaneous resolution of the disease in some
patients. However, a recent study [34] shows
that disease persistence is high and that the
decline in healthcare resource use may be a
consequence of patients being returned to primary care for continuous management (and
thus are not captured in the present study). The
evolution of costs over time suggests that
healthcare resource use is the most intense in
the short term after onset of the disease or at
relapse of symptoms.
Comparison with Previous Studies
The cost burden of pM2M AD patients reported
across other studies varies substantially (between €49 and €1519), likely due to differences
in study design (retrospective, prospective, and
survey), study setting (inclusion of reference
cohort), and type of cost (drugs, primary and
secondary care visits, out-of-pocket expenses,
indirect costs). These differences make comparisons between studies difficult. The estimated cost burden of pM2M AD in the present
study appears to be within the range of cost
burden reported in the published literature.
A German study that included children used a
similar study design as the present study (retrospective with 8-year follow-up), and reported
an average annual cost for AD of €194 in mild
patients and €417 in moderate patients [20].
The average annual cost per patient (over
5 years) in the present study was €224. Another
168
retrospective study in a French setting reported
the average cost of medications per patient used
during the first year of follow-up to be €175 in
the eczema cohort compared with €99 in the
reference individuals. The average cost of dispensed drugs in this study was €225 and €67 per
patient in the pM2M AD cohort and reference
cohort, respectively [35]. Two Nordic studies
(survey and prospective study) included cost of
primary and secondary care visits together with
cost of medications [36] and indirect cost [37],
but neither differentiated results by severity.
The survey study estimated the incremental
cost of patients experiencing eczema symptoms
at €410, while the prospective study estimated
the incremental cost at €291. Finally, an Italian
survey reported an annual average cost of €900
in mild patients and €1519 in moderate patients
[19].
Strengths and Limitations
A major strength of this study is the use of two
large national databases with complete population-level coverage to identify the study population. This study, therefore, provides a
complete account of healthcare resource use in
secondary care and for dispensed drugs originating from both primary and secondary care.
Further, through the use of these national
databases with long follow-up, it was possible to
identify a large study population of pM2M AD
patients for inclusion in this study (N = 87,721).
At the same time, we used a look-back period of
at least 3.5 years which increases the likelihood
that the index date represents the initiation of
newly clinically managed AD rather than a
relapse of this chronic disease. Additionally, a
matched reference cohort (non-AD) was identified from the national population register to
allow for comparisons.
Three key factors contribute to possible bias
in the study results. First, initial contact with
the healthcare services in Sweden for mild, nonacute diseases is often in primary care. The
present study collected primary care data for
dispensed medications but not for diagnoses.
Therefore, the complete economic burden of
mild-to-moderate AD is likely higher than
Dermatol Ther (Heidelb) (2021) 11:161–172
estimated in this study since this study does not
include the cost of primary care visits and most
patients with mild-to-moderate atopic dermatitis are treated by primary care physicians.
Second, the date for first dispensation of a
TCS/TCI or a diagnosis in secondary care was
used as the index date rather than the date of
primary care diagnosis. This means that patients
treated solely with emollients or lowest-potency
TCS medications were not included in this
study since these agents are available as overthe-counter drugs in Sweden and hence not
captured by the PDR. From this perspective, the
results in this study may therefore overestimate
the economic burden since these ‘‘mildest’’
mild-to-moderate patients are likely to incur
less than average healthcare resource use compared with the average mild-to-moderate AD
patient. On the other hand, emollients are the
basis of treatment for AD in all severities and
the cost of these is not captured by this study.
Third, severity based on clinical assessment
was not available in the administrative registers
used in this study. Therefore, the definition of
mild-moderate and severe AD was based on
treatment class (topical, systemic, phototherapy) where information on potency and treatment concentrations was not available. This
may have led to misclassification as we could
not distinguish drugs with respect to potency
within the class of TCS or concentrations within
the class of TCIs since we only had access to the
first three digits of the ATC codes in the database. Additionally, misclassification may have
occured as mild-to-moderate patients with a
flare may have been treated temporarily with
systemic treatments or may have received phototherapy (this was not available in the database), or severe patients may not have received
systemic treatment for unknown reasons.
Although it was not possible to validate the
severity classification, it follows treatment
guidelines and the percentage of severe patients
in this study (11.7%) is in line with other
studies [2].
In addition, date of death was not included
in this study, and therefore patients were not
censored at death. Since the study population
consisted of pediatric patients, this likely had a
minor impact on the study results. In addition,
Dermatol Ther (Heidelb) (2021) 11:161–172
this study only accounted for direct health care
costs and did not include other types of costs,
such as indirect costs associated with loss of
school days. Finally, another limitation in this
study was the inability to verify the sensitivity
and specificity of the inclusion and exclusion
criteria employed to identify AD cases from
prescription data. However, the algorithm used
in this study was developed by specialists in
dermatology, pharmacoepidemiology, and biostatistics and has been validated in a Danish
setting, yielding a sensitivity and specificity of
74.1% and 73.0%, respectively [38].
CONCLUSION
We evaluated and compared the clinical and
economic burden for a population of 87,721
pediatric patients with mild-to-moderate AD to
that of a randomly selected reference cohort
using longitudinal, population-based data in
Sweden. We also evaluated the clinical and
economic burden in a severe AD cohort.
In the seldom-studied patient group of mildto-moderate AD, the cumulative excess (direct)
societal economic burden of AD was substantial, conservatively estimated to be €118.9 million after 5 years. Albeit the average direct
medical costs per patient was higher in the
severe AD cohort, the societal economic burden
of mild-to-moderate AD is higher due to the
high prevalence. The annual differences in costs
between patient and reference cohorts were
observed to be largest close to time of disease
identification. This estimate includes the
robust approach of including not only direct
AD-related visits, but also any type of secondary
care visits known to be more common in AD
patients than in the general population. The
clinical and economic burden identified in this
study, especially the high use of secondary care
resources in pediatric patients with mild-tomoderate disease suggests a need for further
research to increase treatment options and
improve the management of pediatric AD
patients with mild-to-moderate disease.
169
ACKNOWLEDGEMENTS
The authors of this study would like to thank
Prof. Jacob Thyssen and Drs. Natalia Ballardini
and Anna De Geer for their comments and
input that greatly improved this manuscript.
Funding. This study was sponsored by Pfizer
Inc. The Rapid Service Fee was funded by
Quantify Research AB.
Authorship. All authors meet the International Committee of Medical Journal Editors
(ICMJE) criteria for authorship for this manuscript, take responsibility for the integrity of the
work as a whole, and have provided final
approval of the version to be published.
Medical Writing and Editorial Assistance. Editorial and medical writing support
under the guidance of authors was provided by
Mathias Lilja of Quantify Research AB, and was
funded by Pfizer Inc, in accordance with Good
Publication Practice (GPP3) guidelines (Ann
Intern Med. 2015;163:461–464).
Disclosures. Amy Cha, Joseph C. Cappelleri,
and Maureen P. Neary are employed by Pfizer
Inc. and own Pfizer stock and/or stock options.
William Romero is employed by Pfizer Ltd and
owns Pfizer stock and/or stock options. Dan
Henrohn and Petra Neregard are employed by
Pfizer AB and own Pfizer stock. Kirk Geale is an
employee and board member of Quantify
Research and owns Quantify Research stock
options. Gustaf Ortsäter and Alexander Rieem
Dun are employed by Quantify Research AB.
Quantify Research AB provides consulting and
other research services to pharmaceutical,
medical device, and related organizations.
Quantify Research AB received funding from
Pfizer Inc. to conduct this study and for the
development of this manuscript.
Compliance with Ethics Guidelines. This
study was approved by the Regional Ethical
Review Board in Gothenburg (Dnr: 2019-02986)
and performed in accordance with the ethical
standards in the 1964 Declaration of Helsinki
Dermatol Ther (Heidelb) (2021) 11:161–172
170
and its later amendments. For this type of study,
individual informed consent was not required.
Data Availability. The datasets generated
during and/or analyzed during the current
study are protected under Swedish and European law and may only be accessed following
relevant ethical approvals, data protections
assessments, and compliance with GDPR.
Open Access. This article is licensed under a
Creative Commons Attribution-NonCommercial 4.0 International License, which permits
any non-commercial use, sharing, adaptation,
distribution and reproduction in any medium
or format, as long as you give appropriate credit
to the original author(s) and the source, provide
a link to the Creative Commons licence, and
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