Burden of Atopic Dermatitis

Physicians should be aware of the psychosocial, neuropsychiatric, and physical effects of atopic dermatitis on the patient and family.

Up to 40% of children with atopic dermatitis have atopic comorbidities, but nonatopic comorbidities may also substantially contribute to the disease burden.

Sleep Disturbance

Between 50% and 80% of children with atopic dermatitis have sleep disturbances, and this number may be higher during eczema flares.

Children with atopic dermatitis and their parents report several types of sleep disturbances, including

Difficulty falling asleep (Average sleep onset is approximately 40 minutes.)
Nighttime awakenings (2.7 to 3.5 average awakenings during flares)
Wake time after sleep onset (Staying awake ranged between 0.25 hours and >2 hours.)
Difficulty awaking in the morning (approximately 60%)

Objective sleep studies show that children with atopic dermatitis

Have less non–rapid-eye-movement sleep
Have more sleep fragmentation
Have more awakenings and movement during sleep (including scratching) than healthy children
Are at higher risk for obstructive sleep apnea

The chronic sleep disturbance resulting from nighttime itching can lead to behavioral and physiological challenges, including

Poor memory
Irritability
Difficulty concentrating
Decreased school performance
Impaired linear growth

Further, lack of sleep in children is indicated in multiple morbidities, including

Hypertension
Obesity
Headache
Depression

Read about Healthy Sleep Practices.

Quality of Life

It is difficult to overstate the detrimental effect that atopic dermatitis symptoms have on children and their families.

Research shows that patients with atopic dermatitis have a significantly lower quality of life when compared with individuals who do not have atopic dermatitis.
The quality of life decreases as the severity of atopic dermatitis increases.
The parents of children with atopic dermatitis have significant stress in managing the symptoms and dealing with the associated comorbidities.
Children and families, when surveyed about their health-related quality of life, ranked atopic dermatitis (along with psoriasis) as second only to cerebral palsy as having the greatest effect on their quality of life.
The distress of persistent pruritus for the child and the need to avoid or prevent scratching for the parents are sources of stress and tension between parents and children.

Psychosocial Effects

The psychosocial effects of atopic dermatitis on children are marked.

Children with atopic dermatitis have fewer friends and participate in fewer group activities.
School-aged children with atopic dermatitis may be embarrassed by weeping, red, and lichenified skin.
Classmates of children with atopic dermatitis may react negatively to the lesions, causing emotional pain with comments or distancing behaviors.
Active lesions may prevent children from participating fully in school or recreational activities, particularly those involving recreational waters.

Other effects of atopic dermatitis include

Depression
Anxiety
Suicidal ideation
Decreased family functioning

Psychosocial Considerations for Adolescents With Atopic Dermatitis

Adolescents have special needs when it comes to managing atopic dermatitis because they

Are learning to accept responsibility for their lives, including their own health care
Have concerns unique to their age group, which include
- A focus on appearance
- Sports participation
- Tendency to question authority, including health advice
- Immature self-regulation mechanisms

Adolescents may develop their own treatment routines that differ from those prescribed and may hold incorrect beliefs about the mechanism of action of the medications. Physicians should

Ensure that disease management education is repeated for the adolescent and demonstrate treatment procedures as children age into adolescence, particularly focusing on appropriate use of topical corticosteroids with emollients.
Address topical corticosteroid phobia (also known as steroid phobia) with adolescents. Rates of topical corticosteroid phobia in people with atopic dermatitis range between 21% and 83%.

Choosing Cosmetics

Adolescents with atopic dermatitis need help with choosing appropriate cosmetics. Keep in mind that

Fragrances (including botanical scents) may trigger a flare.
Water-based cosmetics contain preservatives that may trigger a reaction.
Cosmetics that shimmer tend to contain substances that trigger a flare in some adolescents.
Mineral-based cosmetics may be the least likely to trigger a reaction.
Cosmetics may be used by both male and female adolescents.

Applying and Removing Cosmetics

New products should be used one at a time, keeping at least 7 days between additions.
Try new products on a small patch of the arm before applying to the face.
Dab makeup on freshly moisturized skin using clean fingers (not brushes or sponges that can harbor bacteria). Avoid rubbing the skin.
If treatment includes using a topical medication on the face, apply this before applying cosmetics.

The National Eczema Foundation provides a seal of approval for products that are hypoallergenic. Choosing these products may avoid flares in those with atopic dermatitis. Patients and parents can review the list of moisturizers, cleansers, hair products, and other household items on the National Eczema Foundation website or look for the seal on the product itself.

Hair Removal

Let adolescents know that

Dry shaving damages the skin and can lead to a flare.
Moisturizers for shaving the face or legs should be applied before and after shaving.
Razors should be changed often to avoid bacterial buildup on the razor and the need to press hard or to use excessive number of strokes.
Using electric razors may work best to avoid ingrown hairs and skin damage.

Pampering the Skin

Adolescents are often active, and sweat can exacerbate skin symptoms. To mitigate the detrimental effects of sweaty workouts

Gently towel off sweat during a workout.
Shower directly after a workout or sports activity to avoid the drying effect of sweat and salt on the skin.
Avoid hot showers and use lukewarm or cold water instead.
Wear loose-fitting clothing to avoid rubbing.
Choose low-intensity activities.
Slowly work up cardiovascular endurance to avoid the excessive sweating that occurs during high-intensity workouts.

Adolescents may also be interested in spa-like activities for personal comfort or as an activity shared with friends. Let adolescents know the risks and benefits of the following spa-like activities:

Skin scrubs: Facial or skins scrubs tend to cause micro-abrasions and should be avoided; this includes facial brushes that are designed to remove dead skin.
Non-disposable cooling masks or ice globes: These may cool down the face, especially during a flare. Be sure to clean these with unscented, safe soap in between uses.
Silk pillowcase: The smooth fibers of silk tend to minimize catching and pulling on abraded skin; also, silk is naturally hypoallergenic.
Facial steamer: The warmth of steamers may trigger a flare, but adolescents not prone to facial or neck flares may wish to try this and moisturize afterward.

Helping Teens Cope

Providing adequate education is paramount in helping teens learn to take responsibility for their skin care. Specific advice includes

Speak directly to adolescents using motivational interviewing techniques. This helps teens to begin to take charge and feel empowered and reduces the likelihood of parental conflicts.
Speak to the parents of adolescents about the best ways to encourage them to manage their own care appropriately.
Encourage teens to keep track of their triggers in a journal.
Discuss with adolescents a daily routine that includes skin care and medication, taking into consideration their lifestyle. Refer adolescents to various types of time management tools that are available, including digital reminder systems and simple journaling and list making.
Encourage teens to get adequate sleep, providing sufficient education about the detrimental physical effects of lack of sleep on atopic dermatitis and other facets of health.
Administer a validated depression instrument for each adolescent visit. When appropriate
- Provide relevant advice for dealing with depression symptoms.
- Provide suicide hotline information.
- Provide a referral to a mental health professional.

Effect on Parents and Family

Parents of children with atopic dermatitis report a significant effect on their family functioning. Key themes are

The time needed to administer treatment (Parents of children with moderate and severe atopic dermatitis may spend up to 3 hours a day on treatment.)
The effect on the parent-child relationship
Parent mental well-being and ability to function well at work
Increased financial burden of treatment
Relationship conflicts
Distress at seeing their children experience the effects of atopic dermatitis
Depression and feelings of hopelessness and guilt (The rate of depression in mothers of children with atopic dermatitis is twice as high as in mothers of children who do not have atopic dermatitis.)

Approximately 30% of parents of a child with atopic dermatitis report co-sleeping.

This is likely because of the disrupted sleep patterns of a child with atopic dermatitis.
Co-sleeping may be responsible for some of the most commonly reported stressors, including
- Fatigue
- Absence of privacy
- Lack of sleep

Determining the psychological effect of atopic dermatitis on the family is useful as part of a child’s treatment and management plans.

Addressing the psychosocial aspects of life with atopic dermatitis may include multidisciplinary group education.
Psychological and educational interventions as an adjunct to conventional treatment enhance the effectiveness of topical therapy.
Relaxation methods may reduce the severity of atopic dermatitis when compared with discussion alone.

Comorbidities

Children with atopic dermatitis are at risk for multiple types of comorbidities, including:

Other atopic disorders
Food allergies
Asthma
Allergic rhinitis
Nonatopic conditions, including
- Infections
- Depression
- Anxiety
- Neuropsychiatric disorders such as attention-deficit/hyperactivity disorder

Food Allergies

Food allergies in children are a common concern for parents and pediatricians.

The prevalence of food allergy in all children in the first 5 years after birth is approximately 5%.
In children with atopic dermatitis, the prevalence of food allergy is approximately 30% to 40%.
Children with atopic dermatitis who have food allergy often have earlier-onset and more severe atopic dermatitis.
Children with early-onset atopic dermatitis have a higher risk of developing food allergies than those with later-onset atopic dermatitis.
Up to 80% of children with atopic dermatitis have high food-specific IgE concentrations, even in the absence of a true food allergy.
In a study with 262 children with atopic dermatitis, IgE sensitization to food was common in those younger than 2 years.

Relationship Between Atopic Dermatitis and Food Allergy

Atopic dermatitis is considered a major risk factor for developing food allergies; however, the role of food allergy in the pathogenesis and severity of atopic dermatitis is controversial.
Having a food allergy predicts a poor prognosis of severe and persistent atopic dermatitis, but food allergy does not necessarily cause atopic dermatitis.
More than 90% of parents incorrectly believe that ingestion of food allergens is the sole or main cause of their child’s skin disease.
The resulting focus on food allergy can result in
- Unnecessary elimination diets
- Potential nutritional concerns, such as protein or micronutrient malnutrition or deficiencies
- Misdirection of treatment away from the skin, leading to undertreatment
Effective treatment should focus on skin interventions and, when successful, tends to allay parental concern about food allergy.

Evaluating for Food Allergies

Allergy evaluation (specifically limited evaluation to milk, egg, peanut, wheat, and soy) may rarely be considered in children younger than 5 years with severe atopic dermatitis if one of the following is true:

The child has persistent atopic dermatitis despite optimal management and topical therapy.
The child has a reliable history of an immediate cutaneous reaction after ingestion of a specific food.
It is important to note that food allergen panel specific IgE testing often results in mis-diagnosis of food allergy and is not recommended by Allergists/Immunologists or Dermatologists.

Allergies Rhinitis

Children 5 years and older have mostly inhalant allergy (rather than food allergy) as the significant allergy associated with their atopic dermatitis.
Approximately 10% of children without atopic dermatitis are allergic to inhaled antigens, while far greater numbers of children with atopic dermatitis are sensitive to inhaled allergens (70% for mites, 70% for cockroach, 63% for house dust, 50% for mold, 43% for grass).
Atopic dermatitis skin lesions likely allow transcutaneous sensitization leading to the development of allergic rhinitis, rather than inhalation of antigens resulting in sensitization.

Asthma

As many as 30% (Sources: Journal of Allergy and Clinical Immunology, Allergy) of children with atopic dermatitis go on to develop asthma.

The presence of atopic dermatitis is 1 of 2 major criteria for predicting eventual asthma in a wheezing infant according to the Asthma Predictive Index.
Children with the filaggrin mutation and early-onset atopic dermatitis are more likely to develop asthma.
Excessive smoke exposure over time may increase the risk of asthma in children with the filaggrin mutation.

Children with atopic dermatitis may become transcutaneously sensitized to allergens that then manifest as food or inhalant allergies. Therefore, preserving skin barrier function may prevent the progression from atopic dermatitis to sensitization to asthma.

Nonatopic Comorbidities

Depression and Suicidal Ideation

The presence of atopic dermatitis in children and adolescents is associated with depression.

The depression is possibly attributable to pruritus and the psychosocial effects of the disease. (Sources: Journal of Dermatological Science, Journal of Investigative Dermatology)
A 2018 systematic review and meta-analysis showed a positive correlation between atopic dermatitis and depression in children.
There is a positive correlation between adolescents with atopic dermatitis and suicidal ideation.

Anxiety

Attention-Deficit/Hyperactivity Disorder

Children with atopic disorders appear to be more at risk for attention-deficit/hyperactivity disorder (ADHD).

Results of a systematic review show an association between ADHD and atopic dermatitis regardless of age, gender, or other psychiatric disorders.
Children with atopic dermatitis and other atopic diseases are at greater risk of developing ADHD, and the risk increases with the number of atopic diseases an individual has.
Some evidence indicates that a higher severity of atopic dermatitis increases the risk of ADHD.
Antihistamine use in children with atopic dermatitis (as a proxy for severity of pruritus) is associated with ADHD.
As the number of atopic dermatitis–related physician visits increases (which indicates increased disease severity), so does the risk of ADHD.

Some evidence shows an independent and strong association between ADHD and atopic dermatitis in children with sleep problems. This association was not found in children without sleep problems.

Last Updated

06/11/2021

Source

American Academy of Pediatrics

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The development of this information was made possible through support from Sanofi and Regeneron.