"Medical Journeys" is a set of clinical resources reviewed by physicians, meant for the medical team as well as the patients they serve. Each episode of this 12-part journey through a disease state contains both a physician guide and a downloadable/printable patient resource. "Medical Journeys" chart a path each step of the way for physicians and patients and provide continual resources and support, as the caregiver team navigates the course of a disease.
Atopic dermatitis, also known as atopic eczema, significantly impacts the overall health and quality of life in affected children and adults. This chronic, pruritic inflammatory skin disease is the leading contributor to skin-related disability worldwide, and the comorbidities associated with it further increase the burden of disease.
Atopic dermatitis is linked to other immunoglobulin-E (IgE)-associated inflammatory disorders, including allergic rhinitis, asthma, and food allergies. Ongoing research into the associations between atopic dermatitis and various autoimmune, metabolic, cardiovascular, and mental health conditions holds the potential for improving patient outcomes and reducing overall disease burden.
"This is such a common disease and has so many life-altering complications that we really need to be paying a lot of attention to it," Amy S. Paller, MD, chair of the Department of Dermatology and director of the Skin Biology and Diseases Resource-Based Center at Northwestern Medicine Feinberg School of Medicine in Chicago, told MedPage Today.
The American Academy of Dermatology (AAD) has started a four-part update to the organization's 2014 guidelines on atopic dermatitis. The first part, issued in July 2022, consists of 32 evidence-based statements on the association between atopic dermatitis in adults and an expanding list of potential comorbidities (Guideline #4 will focus on considerations exclusive to pediatric atopic dermatitis, including comorbidities).
Following a systematic review of the literature and a meta-analysis, the AAD's multidisciplinary work group reached consensus on the association between atopic dermatitis and select allergic, atopic, immune-mediated mental health and bone conditions, as well as skin infections. The panel found a small absolute risk of hypertension attributable to atopic dermatitis, and inconclusive evidence for the association with autism spectrum disorders, myocardial infarction, and stroke. The evidence for a link between atopic dermatitis and diabetes suggested an inverse association.
Although the guideline doesn't make recommendations for screening or management of comorbidities in adults with atopic dermatitis, it is crucial that clinicians be aware of these comorbidities, said Robert Sidbury, MD, MPH, and Dawn M.R. Davis, MD, co-chairs of the AAD's atopic dermatitis guideline work group.
"Our concern was to assess the evidence to help stakeholders understand which associations were truly evidence-based and what the strength of that evidence might be," said Sidbury, chief of Dermatology at Seattle Children's Hospital and the University of Washington School of Medicine.
"There was clear recognition that atopic dermatitis has a broader impact beyond just the skin and many effects on mental and physical health," said AAD guideline work group member Jonathan Silverberg, MD, PhD, of George Washington University School of Medicine and Health Sciences in Washington, D.C. "Although many of the associations are not brand new, I think they're still not on the radar of most clinical dermatologists who see patients with atopic dermatitis."
'Whole-Patient Care'
The focus on comorbidities reflects the need for whole-patient care, said Davis, professor of Dermatology and Pediatrics at the Mayo Clinic in Rochester, Minnesota. "The goal is to ensure our atopic dermatitis patients receive the most comprehensive and optimal care possible. That may include active screening and management by the dermatologist, or it may involve collaboration with the patient's primary care physician or another specialist."
Another member of the work group, Elaine C. Siegfried, MD, professor of pediatrics and dermatology at Saint Louis University School of Medicine, agreed: "I think that increasingly, in our fee-for-service world, many specialists who are pressed for time are focused on just their own little area and miss the opportunity to recognize the whole patient, which I think is really important to do. These patients have lots of comorbidities, and it takes time to recognize them."
Some comorbidities, such as anxiety and depression, can be directly related to the severity of atopic dermatitis. These tend to improve with either effective treatment that improves the skin or if not, a referral to a mental health professional. Other comorbidities, though, such as skin infections, always require additional treatment, while comorbidities such as cardiovascular disease "are the downstream products of chronic uncontrolled disease," Silverberg said.
"It is very much within our scope to recognize this as part of the extended burden of the disease, and partially as a rationale for why we need to achieve better long-term control of the disease in order to reduce these comorbidities or other outcomes," he explained.
In the meta-analysis related to the AAD guideline, the pooled prevalence of asthma in adults with atopic dermatitis was 24.8%, with the evidence suggesting that the risk of asthma was triple that found in the general population, the authors said.
Asthma, Alopecia, Osteoporosis
Severe atopic dermatitis appeared to have a much stronger association with asthma than mild or moderate disease, a finding similar to studies showing that the odds of IgE-mediated food allergy increased with atopic dermatitis disease severity. Atopic dermatitis was consistently associated with allergic rhinitis, but there was little evidence to support the associations between atopic dermatitis and allergic conjunctivitis or eosinophilic esophagitis, the AAD guideline notes.
Atopic dermatitis was associated with alopecia areata in multiple epidemiologic studies. In a Danish study, the adjusted odds ratio for the association was an astonishing 26. On the other hand, the work group found no evidence of a statistically significant association between atopic dermatitis and a higher likelihood of alopecia totalis or universalis.
Patients with atopic dermatitis had an increased risk of osteoporosis, but only a modestly elevated risk of fracture overall. However, in a British study, the presence of both atopic dermatitis and osteoporosis increased the rates of spinal, pelvic, and hip fracture by 200%, 66%, and 50%, respectively. More research is needed to understand the mechanism behind this association, but in the meantime, the guideline authors suggested that patients prescribed oral corticosteroids for atopic dermatitis may be candidates for fracture prevention therapy.
Cardiovascular Disease, Skin Infections
Mounting epidemiologic evidence of small associations between atopic dermatitis and cardiovascular conditions remains controversial, the guideline notes. To date, there is no evidence to support "increased cardiovascular screening or treatment for people with atopic dermatitis beyond what is recommended for the general population," the work group concluded.
"We did find that hypertension and coronary artery disease are probably associated with atopic dermatitis, though [the associations with] stroke and myocardial infarction risks were uncertain," Sidbury told MedPage Today. "We have watched a similar story play out with psoriasis over the past 10 years, so we will await more data in this area with regard to atopic dermatitis."
Atopic dermatitis is associated with staphylococcal skin infections, and these patients have a risk of potentially life-threatening eczema herpeticum that is twice that of the general population.
Depression and Anxiety
In an analysis of four pooled studies including more than 11,000 patients, atopic dermatitis was associated with twice the odds of self-reported or clinician-diagnosed clinical depression compared with controls, the guidelines note. Another analysis showed similar results for anxiety, the authors added. There was high-certainty evidence for the association with suicidal ideation but conflicting evidence for an association with suicidal death. Evidence to support a potential association between atopic dermatitis and alcohol use or cigarette smoking was limited.
"Symptoms of depression and anxiety are unfortunately very common in atopic dermatitis, and particularly increased in people with moderate to severe atopic dermatitis," Silverberg said. "In a perfect world with limitless resources, I would say that it is advisable to screen all atopic dermatitis patients for depression and anxiety. However, recognizing the importance of prioritizing resource allocation, special attention should be paid to patients with severe itch and lesional severity."
A Complex Disease
The AAD guideline is "a good reminder to the medical community, patients, and their caregivers that atopic dermatitis is complex," Davis said. "Education is imperative to feel empowered. Most patients require more than one visit to an experienced professional to feel prepared to manage their disease effectively."
During the initial visit, adults with significant atopic dermatitis should be given a clear-eyed view of the potential risks for comorbidities, but the information should be provided in such a way that patients don't feel overwhelmed, Sidbury advised.
"The most effective clinical cocktail is a mixture of disease basics including skin care, safety and efficacy of available therapies, expected natural history, potential comorbidities, and hope," he said.
Read previous installments in this series:
Part 1: Atopic Dermatitis: Reasons for Optimism
Part 2: Atopic Dermatitis: The Latest on Diagnosis and Assessment
Part 3: The Many Ways to Measure the Severity of Atopic Dermatitis
Part 4: Case Study: Why Is This Young Boy's Atopic Dermatitis So Resistant to Treatment?