Recognising Eczema as a Chronic Disease

ADJOURNMENT MOTION

The Deputy Leader of the House (Mr Zaqy Mohamad): Mr Speaker, Sir, on behalf of the Leader, I beg to move, "That Parliament do now adjourn."

Question proposed.

Recognising Eczema as a Chronic Disease

7.03 pm

Ms Tin Pei Ling (MacPherson): Mr Speaker, I call upon the Government to take a fresh look at a commonly occurring chronic skin ailment, atopic dermatitis, also known as eczema. With a high prevalence index of two in 10 children and one in 10 adults in Singapore, I believe all of us will know of someone who is suffering from this chronic skin condition.

Atopic dermatitis is a chronic inflammatory skin condition that waxes and wanes due to a defective skin barrier and an altered immune system response. For individuals with mild eczema, it feels like an itchy skin rash on a localised body part, but the symptoms are manageable with the application of emollients, topical steroids and other topical anti-inflammatory medications.

However, for patients with moderate-to-severe eczema, they are tormented by persistent intense flares and itchiness on a large area of the body that oozes fluid or bleeds. They have widespread inflamed skin and these patients usually require treatments with higher potency medications because they tend not to respond to topical therapies.

Unlike its milder variant, moderate-to-severe eczema causes widespread symptoms that not only affect daily life routine but also their mental well-being. Itch, depression, sleep disturbance and anxiety are the most common manifestations among eczema patients.

There is no cure for eczema and patients can only try to relieve and manage the symptoms through medications and creams. It is reported that eczema has the highest burden among all skin diseases, mainly owing to its high prevalence globally. The burden of eczema is ranked in the top 15 among all non-fatal diseases and significantly higher when compared with other skin diseases. This chronic inflammatory skin condition affects more than 31 million Americans. And in Singapore, it is estimated to affect 20% of children and 11% of adults. At the National Skin Centre, 14,000 new eczema cases were seen in the year ending 31 March 2023 versus 9,406 cases in 2008. Notably, there was an estimated 20% to 30% increase in eczema patients during the COVID-19 pandemic, as reported by The Straits Times.

Moderate-to-severe eczema can cause symptoms intense enough to affect the patients’ quality of life. The constant uncontrollable itchiness, pain and other symptoms can cause loss of sleep, making it difficult to focus in school or at work and making it hard to participate in activities. Furthermore, conventional treatments alone are usually ineffective in relieving the inflammation on the skin in patients with moderate to severe eczema.

Besides having to constantly battle against the physiological symptoms, these patients are burdened psychologically because of a vicious feedback loop of scratching an itch that would not go away. Unfortunately, the act of scratching causes further damage to the skin, developing into lesions that loop the patients back with intense itch all over again. Aggravating matters further, researchers discovered that the link between mental health struggles and eczema is bidirectional; that is, they can exacerbate each other, creating a vicious cycle of distress and flare-ups. Eczema flares can lead to repeated infections, requiring inpatient care for three to five days per episode.

Moderate-to-severe eczema makes it challenging for patients to focus on their responsibilities at work and in life, as the intense itching is distracting and debilitating. Furthermore, sleep issues caused by eczema can add fuel to fire because it disrupts mental and cognitive functions, making it difficult to think, focus and go about their daily routines. A 2020 study in The British Journal of Dermatology found a connection between eczema severity and work productivity. According to the findings, the more severe the eczema, the more work productivity declines, which then negatively affects a person’s quality of life.

Moreover, the itch tends to be worse at night, causing impaired sleep. Poor sleep creates difficulties in regulating emotions that, in turn, leave a person vulnerable to depression.

There was a study presented at the 2024 American College of Allergy, Asthma and Immunology Annual Scientific Meeting, where it was reported that 72% of people with eczema have adverse mental health symptoms for one to 10 days a month, with 17% having symptoms for more than 11 days per month. Furthermore, recent research published in Nature, a prominent scientific publication, revealed that there is significantly higher prevalence of clinical depression, anxiety disorder and suicidal ideation among patients with skin disorders compared to the general population.

Mr Speaker, I have shared the challenges and sufferings of adult patients plagued by moderate-to-severe eczema. The adverse impacts of moderate-to-severe eczema on young children and adolescents are definitely no less. The burden of the skin condition falls on both the child and caregiver. Esteemed Members in this House who are parents will understand the anxiety and additional stress of caring for a child who comes down with a treatable condition. We need to consider the magnitude of stress for both the child and caregiver coping with physiological, psychological and psychosocial impairments.

A 2019 study conducted in France by skincare brand La Roche-Posay highlighted its psychological consequences. It found that more than 60% of children with eczema reported having a lack of concentration in class due to constant itching. This aligns strongly with several systematic reviews and large population-based surveys from Germany, Taiwan, Japan and the United States (US) that demonstrated a positive relationship between eczema and attention-deficit/hyperactivity disorder (ADHD).

In 2006, the economic burden of eczema in the US was estimated to be $1.6 billion, of which $1 billion were attributed to direct healthcare costs and $600 million were attributed to lost productivity. In Singapore, the average annual cost per child with eczema was estimated at US$7,943 based on 2017 prices. The major cost was for informal caregiving, and that will be 46% of the total cost, followed by out-of-pocket expenses, about 37% of the total cost. Healthcare utilisation contributed to 17% of the total cost, of which 43% was for medication. These findings were based on a study performed by the Nanyang Technological University Lee Kong Chian School of Medicine, KK Women's and Children's Hospital (KKH) and the National Skin Centre in 2019.

It is important for us to also consider the substantial cost holistically and that includes cost from informal caregiving, such as preparation of special meals due to dietary restrictions and provision of emotional care. Additionally, there are out-of-pocket expenses from purchasing moisturising creams and laundry costs that are not subsidised by the healthcare system. In the US, these out-of-pocket expenses averages to about US$3,000 per child per year. Hence, if we can manage eczema better, we can reduce the ancillary or indirect costs.

Even though topical steroids have been the workhorse treatment for eczema patients in providing relief to the inflammation and itch, it may not work for everyone, particularly patients with moderate-to-severe eczema, where topical steroid becomes ineffective and unfeasible over a large area of the body over long periods of time.

Hence, the development of newer treatments like biologics that offer high efficacy and safety vis-à-vis conventional immunosuppressant. Conventional immunosuppressants like Methotrexate, which is also used in treating certain types of cancer, or Ciclosporin, also used for organ transplant, pose safety issues.

Dupilumab is the world’s first biologic drug approved for moderate to severe eczema and the only targeted therapy approved in Singapore. Dupilumab is a safe and effective treatment that has been approved in Singapore for children aged six months and older, and around 60% of people will see at least a 75% improvement in their condition. Dupilumab works by reducing inflammation that is thought to lead to eczema flares. It does not suppress the immune system, so it does not increase the risk of developing a serious infection like tuberculosis. Clinical trials of Dupilumab in adults and children have shown that it significantly reduces eczema severity compared with placebo, as well as a rapid reduction in itch and an improvement in sleep and quality of life.

Allow me to share the case of a young boy. Let us call him AQ, who was a patient at KKH. AQ apparently only slept an average of three to four hours a day, broken up, for three years. He was only 14 years old when he first met his doctor during his admission for an infectious flare over his face. He could barely open his eyes or mouth due to yellow crusts all over his entire facial skin. He was subsequently discharged but re-admitted to the children’s intensive care unit for hypotension, which is extremely low blood pressure, on Christmas Eve in the same year. Blood tests went on to confirm adrenal insufficiency because of the chronic use of topical steroids and systemic steroids from another centre and from general practitioners for his bad eczema. Yet, after using Dupilumab, his skin cleared up by almost 90% and could finally enjoy uninterrupted sleep of seven hours. He also reportedly became more confident, more cheerful and his academic results improved.

Looking elsewhere, recent analyses of the cost-effectiveness of Dupilumab in treating moderate-to-severe eczema provide compelling evidence for its economic viability. A study from Italy demonstrated that Dupilumab yields an incremental cost- effectiveness ratio of €33,918 per quality-adjusted life year, below the willingness-to-pay threshold. In the US, a lifetime Markov model revealed an incremental cost-effectiveness ratio of $124,500 per quality-adjusted life year, with Dupilumab showing greater cost-effectiveness for severe cases.

Additionally, a US payer perspective analysis established that Dupilumab remains cost-effective at an annual maintenance price, ranging from $29,000 to $40,000, especially for patients classified as having severe eczema. Collectively, these findings underscore the long-term economic benefits of incorporating Dupilumab into treatment protocols for patients inadequately managed by traditional therapies for adults and adolescents.

Returning to Singapore's context, however, it is still costly. Each injection costing almost $1,000 per injection every fortnight, or $2,000 per month, at public healthcare institutions, such as the National Skin Centre. Consider the gross median monthly income data of full-time employed residents from the Ministry of Manpower, it is challenging for a Singaporean patient earning, say, a median wage of $5,000 to have adequate disposable income to access this relatively costly treatment regime, let alone sustaining it long enough to have visible improvements in condition.

Besides the biologics, there is a newer class of drugs approved in Singapore for eczema, known as Jak inhibitors, which are oral medications that are typically taken once a day. Most Jak inhibitors are approved for use in adult eczema, with only a few options for children aged 12 years and above. However, these medications cost $6,000 to $10,000 a year and they suppress the body's immune system and may, therefore, cause potentially serious side effects, like heart attack, stroke, blood clots and cancer. Because of the potential risks involved, this medication may not be suitable for patients with hypertension and cholesterol diseases.

Mr Speaker, I would, therefore, like the Ministry of Health (MOH) to consider the following suggestions to help patients cope with the debilitating impacts of moderate-to-severe eczema, by making newer treatments that promise better efficacy and less safety risks available to patients who need them.

First, inclusion of other biologics, such as Dupilumab, into list of subsidised drugs. I understand the Drug Advisory Committee (DAC) has recommended only Abrocitinib, a JAK inhibitor, to be on the list of subsidised drugs because of the cost-minimisation approach, given that Abrocitinib is least costly. However, the use of Abrocitinib, as approved by the Health Sciences Authority, is limited to adults and adolescents, roughly aged 12 years and above.

I would like to implore MOH to consider expanding the assessment criteria beyond cost minimisation, so that paediatric patients who are below 12 years old can have access to other treatment regimens with better efficacy and less risks, such as the use of Dupilumab.

Including Dupilumab to the subsidised drug list will not be unique to Singapore, if so. In Australia, the government pledged over $270 million for new medicine, which includes Dupilumab, in the new Pharmaceutical Benefits Scheme. The scheme is a list of drugs that are subsidised by the government, expecting to benefit more than 3,600 people each year.

Second, inclusion of moderate-to-severe eczema into the Chronic Disease Management Programme (CDMP). I propose including moderate-to-severe eczema as part of the CDMP. Currently, the CDMP covers 23 chronic diseases, and these include Psoriasis, another chronic skin condition. Including moderate-to-severe eczema into the CDMP list will enable early intervention in treating eczema and reduce complications. Eczema patients can also find financial relief for the hefty out-of-pocket payments, with up to $700 of MediSave coverage per year under the MediSave 700 scheme.

In addition, I recommend to specially include mild eczema for children as part of the CDMP. This is to ensure early treatment from young before the condition progresses to moderate or severe.

Third, extend MOH Medication Assistance Fund support to Dupilumab and newer treatments. Due to the high cost of newer treatments for moderate-to-severe eczema, I would like to request that the Ministry include Dupilumab under the Medication Assistance Fund (MAF). This will provide tremendous support for financially burdened patients with moderate-to-severe eczema. We must ensure that Singaporeans who are already underprivileged, do not have to face additional employment, economic and health challenges associated with eczema.

Mr Speaker, my objective of raising this Adjournment Motion is to raise awareness that atopic dermatitis, or eczema, is not simply an "itch and scratch" condition. In the US, a patient with severe eczema could qualify as a person with disability if their conditions significantly limit their major life activities and the patient would then be eligible for Social Security Disability Insurance and Supplemental Security Income. However, I am not arguing for eczema to be considered as a disability. Rather, I am appealing to MOH to consider eczema as a chronic disease requiring more support.

I applaud MOH's recent revision to the public healthcare subsidies which offer more financial relief to eligible patients. However, I urge MOH to continue reviewing healthcare affordability for Singaporean patients struck with moderate-to-severe eczema and also young children with this condition. Strengthening financial and accessibility support will certainly mitigate the long-term debilitating impacts of eczema.

Lastly, I would like to place on record my sincere thanks to Assoc Prof Mark Koh, Head of Dermatology Service in KK Women’s and Children’s Hospital (KKH) and Dr Lynette Wee of KKH for their invaluable input, as well as everyone who has actively voiced out their support and also shared their personal stories with me online after I had filed this Adjournment Motion.

Mr Speaker: Senior Minister of State Janil Puthucheary.

7.21 pm

The Senior Minister of State for Health (Dr Janil Puthucheary): Mr Speaker, Sir, I would like to thank Ms Tin Pei Ling for raising the situation of patients with eczema and for explaining to the House the condition and the symptoms suffered by these patients.

Eczema can affect anyone at any age. As Ms Tin pointed out, in Singapore, about 20% of children and 11% of adults have eczema. Most cases are mild to moderate and, for most patients, the symptoms can be managed with over-the-counter moisturisers, topical and oral medications, self-care measures and the avoidance of triggers. For most patients, this approach works quite well. Ms Tin has highlighted the difficulties faced by the patients that have the most serious forms of atopic dermatitis and eczema.

I thank Ms Tin for her suggestion to include moderate-to-severe eczema into the CDMP. The CDMP is a programme established since 2006, with the intention to improve care for chronic disease patients, by making treatments more accessible and affordable for Singaporeans. Today, the CDMP covers 23 chronic conditions, including common conditions, like diabetes mellitus, hypertension and hyperlipidemia.

Patients with these conditions can use MediSave to pay for the out-of-pocket costs for their outpatient treatment. Those with complex conditions can claim up to an annual limit of $700. They can also tap on Government subsidies of up to $500 per year under the Community Health Assist Scheme (CHAS), if they are eligible for CHAS, and special subsidies of up to $540 per year if they are Pioneer Generation or Merdeka Generation cardholders.

Conditions under CDMP are regularly reviewed by the Clinical Advisory Committee (CAC). This comprises Family Physicians and specialists from the public and private sectors. Gout, allergic rhinitis and chronic hepatitis B were most recently added to the CDMP on 1 July 2022.

In selecting conditions for review for inclusion into the CDMP, the CAC takes into account feedback from medical professionals, patients and the public. The CAC consults clinical experts in various healthcare settings and considers factors, such as the disease burden, potential benefits of early interventions to patient outcomes, and the cumulative cost to the patient from long-term treatment, and the availability of evidence-based clinical guidelines for appropriate care of the condition.

In 2020, the CAC had decided not to include eczema under CDMP. Care practices for eczema currently vary significantly, and there are currently no standardised national guidelines for the treatment of eczema. Without such standardised and accepted guidelines, we may run into challenges, such as overdiagnosis or inappropriate treatment. The Agency for Care Effectiveness at MOH is currently developing these clinical guidelines for the treatment of atopic dermatitis. Once these guidelines have been established, the CAC will review if eczema can be included into the CDMP.

Even though eczema is currently not on the CDMP, patients can already receive subsidies for the treatment of eczema today. Topical steroid creams and oral systemic immunosuppressants, such as ciclosporin, azathioprine, methotrexate and mycophenolate mofetil are listed on the Standard Drug List. Abrocitinib, a Jak inhibitor, as mentioned by Ms Tin, is also listed on the MAF for patients who do not respond adequately to immunosuppressants.

Eligible patients who are prescribed these drugs for eczema can receive up to 75% subsidies at polyclinics and Specialist Outpatient Clinics, or SOCs. Additionally, Singaporeans aged 60 and above can use up to $300 a year of their MediSave, under the Flexi-MediSave scheme to pay for their outpatient eczema treatment and medication at polyclinics, SOCs and CHAS clinics.

I would also like to acknowledge Ms Tin's suggestion to include biologics or monoclonal antibodies, such as Dupilumab, into MOH's list of subsidised drugs. Today, MOH provides subsidies for a list of drugs that are assessed by the DAC to be both clinically- and cost-effective. This ensures that limited healthcare resources are directed to therapies that provide good value compared to existing standards of care and keeps healthcare spending sustainable.

In 2023, the DAC listed Abrocitinib on the MAF for people who do not respond adequately to immunosuppressants. Abrocitinib was assessed to be at least as efficacious as Dupilumab and available at a cheaper price. It is also an oral medication. Dupilumab, an injectable, was not recommended for subsidy, as its benefits do not justify its costs, at the current price proposed by the manufacturer.

Ms Tin mentioned that overseas incremental cost-effectiveness ratios for Dupilumab range from $48,000 to over $160,000 per quality-adjusted life year, or QALY, gained. However, we are unable to rely on cost-effectiveness assessments, if there were significant limitations in the methodology and design of the studies. For example, many published industry-sponsored cost-effectiveness studies provide favourable results due to overly optimistic assumptions made about the clinical outcomes of treatment. The studies may also not be generalisable to our local setting if the price of the medication differs significantly compared to that offered to patients here in Singapore.

Ms Tin had also suggested to allow the use of Dupilumab for children below six. There are several subsidised treatment options available for children, such as topical steroid creams and, for the more severe patients, oral immunosuppressants. We note that some of these young patients may still require Dupilumab if they are not assessed to be suitable for these subsidised treatments.

And notwithstanding the benefits of Dupilumab for this age group, Dupliumab remains non-cost-effective at the population level in this setting. So, if patients face issues affording Dupilumab, they may approach medical social workers at our public healthcare institutions to apply for financial assistance through MediFund.

We will continue to regularly review the list of subsidised drugs to ensure that the list stays relevant to changes in our local population needs, medical practice and the evidence on clinical and cost effectiveness.

Mr Speaker, Sir, MOH will continue to review the adequacy of support for eczema patients, taking into consideration the safety, clinical efficacy and cost-effectiveness of these treatments. No Singaporean will be denied access to appropriate healthcare due to an inability to pay.

Question put, and agreed to.

Resolved, "That Parliament do now adjourn."

Mr Speaker: Pursuant to Standing Order 2(3)(a), I wish to inform hon Members that the Sitting tomorrow will commence at 11.00 am. Order.

Adjourned accordingly at 7.29 pm.