Emergency / crisis support: /emergency
If dupilumab has been declined, a biologic is running out of authorisation, topical medications are hitting MSA limits, or you are experiencing a severe flare without access to treatment — this guide covers the steps.
Severe Flare: Hospitalisation
In extreme cases, severe AD with extensive skin breakdown can require inpatient treatment (IV antibiotics for secondary infection, systemic corticosteroids, wound care). Inpatient treatment is covered under the in-hospital benefit as a general medical admission. Pre-authorise if possible. If urgent or emergency, proceed to hospital — PMB emergency coverage applies.
Eczema herpeticum (viral superinfection with herpes simplex virus) is a dermatological emergency — widespread painful vesicles, fever, and malaise. Seek emergency care immediately.
Common Atopic Dermatitis Financial Crises
- Dupilumab exceptional-needs application declined
- Biologic authorisation expires and renewal is delayed
- Topical medications hitting MSA limits mid-year
- Tacrolimus (Protopic) not on formulary — declined
- Step-therapy requirement preventing timely biologic access
If Dupilumab Was Declined
A first decline of a dupilumab exceptional-needs application is common and frequently reversible. The most common reasons for decline:
- Step-therapy not adequately documented (no systemic therapy trialled)
- Disease severity not objectively documented (no EASI score, no IGA score)
- Application missing clinical photographs
- Prior therapy history incomplete
Step 1: Request the full decline letter with clinical reasoning.
Step 2: Ask your dermatologist to resubmit with an enhanced application: - Objective disease severity score (EASI ≥16 or IGA 3–4) - Complete prior therapy history with outcomes (topicals, cyclosporine/methotrexate — dates, doses, outcomes) - Clinical photographs showing current disease - Dupilumab prescribing information confirming SAHPRA-registered indication for moderate-to-severe AD - Quality-of-life impact (DLQI score if available)
Step 3: Request a peer-to-peer clinical review between your dermatologist and the scheme's medical advisor.
Step 4: If declined through peer-to-peer, formal internal appeal, then CMS escalation.
If Biologic Authorisation Expires
Biologic exceptional-needs authorisations are typically granted for 12 months and require annual renewal. If the renewal lapses and supply is interrupted:
- Contact your dermatologist's rooms immediately to initiate the renewal application
- Ask the pharmacy whether a short bridging supply can be dispensed under the prior authorisation while renewal is processed
- Contact the scheme directly to request expedited renewal processing given the treatment interruption
Do not stop dupilumab abruptly without dermatologist input — rebound flares can occur.
If Tacrolimus Was Declined on Formulary Grounds
Tacrolimus ointment (Protopic) is a steroid-sparing topical especially important for the face, eyelids, and other sensitive areas where topical corticosteroids cause skin thinning. If declined:
Ask your dermatologist to submit a non-formulary clinical motivation: the patient's specific skin areas requiring treatment, documented sensitivity to topical corticosteroids at that site, and clinical rationale for tacrolimus as steroid-sparing therapy. Most schemes approve this with a clear clinical letter.
If MSA Is Depleted and Topicals Are Running Out
Emollients and topical corticosteroids are low-cost but high-volume for severe AD. Once MSA is depleted: - Check whether your plan has an above-threshold benefit (ATB) - Ask your GP whether a smaller quantity can be prescribed at a time to manage the MSA depletion more gradually - Generic topical corticosteroids (generic betamethasone, generic hydrocortisone) are significantly less expensive than branded preparations and are therapeutically equivalent
Triage Table
| Situation | Priority | Action |
|---|---|---|
| Eczema herpeticum (herpes superinfection) | Emergency | Emergency care immediately |
| Severe inpatient-level flare | High | Hospital admission; in-hospital PMB/benefit |
| Dupilumab declined | High | Enhanced resubmission; peer-to-peer; appeal |
| Biologic authorisation expired | High | Urgent renewal; bridging supply request |
| Tacrolimus declined | Medium | Non-formulary motivation letter |
| MSA depleted — topicals needed | Medium | ATB check; generics; partial supply |
Escalation Contacts
Council for Medical Schemes (CMS): 0861 123 267 | www.medicalschemes.org.za AURA Emergency: /emergency
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This page is general information about medical schemes. It is not medical advice: speak to a healthcare professional about your own treatment. Medical aid and gap cover advice is given by Eldon de Waal, a Supervised Representative of Approach Administration (FSP 23579).
Protecting Continuity of Biologic Supply
The single most disruptive financial crisis for severe AD patients on dupilumab is an interruption to biologic supply. To protect continuity:
- Set a calendar reminder 6–8 weeks before your annual exceptional-needs authorisation expires to initiate renewal with your dermatologist's rooms
- Maintain a supply buffer where possible — ask your pharmacist whether an additional month's supply can be dispensed before the current prescription runs out
- If the scheme changes their biologic formulary (e.g., switching from one brand to another due to rebate agreements), ask your dermatologist whether the switch is clinically appropriate or whether a clinical exception for the original product can be maintained
Dupilumab is a long-acting antibody — a gap of 2–4 weeks in dosing will not immediately cause relapse, but a longer gap may. Monitor your skin closely and contact your dermatologist if you notice early signs of deterioration.