Eczema and the Impact on Patients

With a growing interest in atopic dermatitis (AD), researchers have begun to examine the disease from various angles. Whether it is a better understanding of disease progression, emergence of new treatments, or acknowledgement of the impact on patient quality of life (QOL), AD is beginning to have its moment at the forefront of dermatology. Atopic Dermatitis’ association with comorbid atopic disorders, including asthma, allergic rhinitis, and eosinophilic esophagitis, is well established.^1,2 Beyond atopy, AD may be associated with several other comorbidities and dermatologists need to recognize the burden of systemic disease can have on patients with eczema.

Identifying the Burden of Disease

“The first thing to recognize is that examining clinical signs alone is inadequate to identify the severity and burden of AD,” said Jonathan Silverberg, MD, PhD, MPH, in an interview with The Dermatologist.³ “Many patients have mild lesions, but severe itch and sleep loss. These patients warrant more aggressive therapy and go undertreated if dermatologists do not assess the severity of symptoms.”

Dr Silverberg is an associate professor of dermatology, director of the patch testing clinic, and director of clinical research and contact dermatitis at the George Washington University School of Medicine and Health Sciences in Washington, DC. At the most recent American Academy of Dermatology Summer Meeting 2021, Dr Silverberg and Raj Chovatiya, MD, PhD, assistant professor of dermatology and director of the Eczema and Itch Clinic at Northwestern University Feinberg School of Medicine in Chicago, IL, lectured about the methods and techniques dermatologists can use to better address the burden of AD, both of the disease and its iatrogenic impact.

“There are simple tools that are feasible to use in clinical practice, [such as] the Numeric Rating Scale for itch or patient-reported global severity of AD. These and other patient-reported outcomes can improve the recognition of patient-burden,” said Dr Silverberg. Dermatologists can use indices such as the Dermatology Life Quality Index (DLQI) or the Children’s DLQI to review the impact on disease.

“AD is not a condition where we can choose to focus only on one clinical domain, whether it be skin signs, symptoms, or QOL. When you are assessing the severity of AD and its impact on someone’s life, all of those are important parts of the puzzle and no one is more important than the other,” said Dr Chovatiya, almost echoing Dr Silverberg’s statements in another interview.⁵ “Similarly, when you are designing a treatment plan, you need to consider how it could impact their life in a variety of ways, whether it be QOL, or some type of treatment-related adverse event, or the patient’s ability to follow through on the actual treatment plan itself.”

Patients with AD experience a multifaceted impact on their day-to-day activities and QOL.⁶ In addition to physical signs and symptoms such as itch, pain, and impaired sleep, patients with AD also experience issues with relationships (eg, marital status and stability, social life, impact on caregivers), mental well-being (self-esteem, accessing care), productivity in work or schooling, and health care use and costs. And, unlike some dermatologic diseases that may be addressed with monotherapy, the lack of effective treatment options for AD also poses a challenge. AD often requires more than one therapy to target the various factors associated with worsening severity, meaning increased time spent managing the disease for the patient and their caregivers.

The age affect. AD’s burden can even vary vary across the lifespan. “We recently published a global systematic literature review and meta-analysis of the regional and age-related differences of AD,” explained Dr Silverberg. In this study,⁷ Yew et al identified that children and adults may have different features associated with their disease presentation. For example, children tended to have dermatitis of eyelids, auricle, and ventral wrist, exudative eczema, and seborrheic dermatitis-like features, vs adults presenting with features traditionally associated with chronic disease
(eg, erythroderma, ichthyosis, palmar hyperlinearity, keratosis
pilaris, hand/foot dermatitis, dyshidrosis, prurigo nodules, and papular lichenoid lesions), said Dr Silverberg. Delaying the diagnosis and referral to a specialist, major challenges for the patients with AD,⁸ could mean delaying treatment, compounding the stress and impact of an already debilitating disease.

Comorbidities. Research into the comorbidities of AD suggest that eczema is a systemic disorder.² Brunner et al discussed the affiliation between AD lesions and epidermal hyperplasia, T-cell and dendritic cell infiltrates, and increased inflammatory processes. These findings were noted to be similar to another well-known and now well-studied immune-mediated inflammatory disease: psoriasis.² Chronic inflammation may also be a possible linking factor between AD and cardiovascular disease.^9,10

The relationship between AD and autoimmune diseases is also evident, though more study is needed to understand the quality of the association. Autoimmune diseases of the dermatologic, gastrointestinal, and rheumatologic origin are most implicated, including alopecia areata, chronic urticaria, ulcerative colitis, Celiac disease, and rheumatoid arthritis.¹¹ Other potentially associated autoimmune diseases, which impact QOL in their own way, include endocrine-based diseases such as Graves disease and type 1 diabetes.

As previously mentioned, the mental well-being of patients with AD as well as their families and caregivers can add to the disease burden. Sleep loss, itching, social isolation, and neuroinflammation are all thought to contribution to increased rates of anxiety, depression, and suicidality in patients with AD.¹² For caregivers and family, there could be a negative
effect on martial conflict,¹³ family dynamics,¹⁴ and caregiver ability to manage pediatric AD.¹⁵

Next Steps for Providers

Proper management of AD, based on severity as defined by QOL and comorbidities, is important to lightening the burden of the disease on patients. Dermatologists should work to recognize the impact AD has on their patients by figuring out improvements are most important, and personalizing their care plan accordingly. Identifying these components within the shared decision-making model could mean getting patients the care they need sooner. n

References
1. Paller A, Jaworski JC, Simpson EL, et al. Major comorbidities of atopic dermatitis: beyond allergic disorders. Am J Clin Dermatol. 2018;19(6):821-838. doi:10.1007/s40257-018-0383-4

2. Brunner PM, Silverberg JI, Guttman-Yassky E, et al. Increasing comordities suggest that atopic dermatitis is a systemic disorder. J Investig Dermatol. 2017;137(1):18-25. doi:10.1016/j.jid.2016.08.022

3. Dr John Silverberg: insights into atopic dermatitis. The Dermatologist. Published August 10, 2021. Accessed September 3, 2021. https://www.hmpgloballearningnetwork.com/site/thederm/qas/dr-john-silverberg-insights-atopic-dermatitis

4. Chovatiya RJ, Silverberg JI. Addressing the iatrogenic burden of atopic dermatitis. Presented at: American Academy of Dermatology Summer Meeting 2021; Tampa, FL; August 5-8, 2021.

5. Mateja L. Defining iatrogenic burdens in atopic dermatitis. The Dermatologist. 2021;29(6):34,36. Accessed September 3, 2021. https://www.hmpgloballearningnetwork.com/site/thederm/nea-approved-features/defining-iatrogenic-burdens-atopic-dermatitis

6. Drucker AM, Wang AR, Li WQ, Sevetson E, Block JK, Qureshi AA. The burden of atopic dermatitis: summary of a report for the National Eczema Association. J Investig Dermatol. 2017;137(1):26-30. doi:10.1016/j.jid.2016.07.012

7. Yew YW, Thyssen JP, Silverberg JI. A systematic review and meta-analysis of the regional and age-related differences in atopic dermatitis clinical characteristics. J Am Acad Dermatol. 2019;80(2):390-401. doi:10.1016/j.jaad.2018.09.035

8. Guttman E, Nosbaum A, Simpson E, Weidinger S. Pioneering global best practices in atopic dermatitis: results from the Atopic Dermatitis Quality of Care Initiative. Clin Exp Dermatol. Published online August 11, 2021. doi:10.1111/ced.14880

9. Thyssen JP, Halling-Overgaard A-S, Andersen YMF, Gislason G, Skov L, Egeberg A. The association with cardiovascular disease and type 2 diabetes in adults with atopic dermatitis: a systematic review and meta-analysis. Br J Dermatol. 2018;178(6):1272-1279. doi:10.1111/bjd.16215

10. Ascott A, Mulick A, Yu AM, et al. Atopic eczema and major cardiovascular outcomes: a systematic review and meta-analysis of population-based studies. J Allergy Clin Immunol. 2019;143(5):1821-1829. doi:10.1016/j.jaci.2018.11.030

11. Ivert LU, Wahlgren C-F, Lindelöf B, Dal H, Bradley M, Johansson EK. Association between atopic dermatitis and autoimmune diseases: a population-based case-control study. Br J Dermatol. 2021;185(2):335-342. doi:10.1111/bjd.19624

12. Silverberg JI. Comorbidities and the impact of atopic dermatitis. Ann Allergy Asthma Immunol. 2019;123(2):144-151. doi:10.1016/j.anai.2019.04.020

14. Han JW, Lee H. Actor and partner effects of parenting stress and co-parenting on marital conflict among parents of children with atopic dermatitis. BMC Pediatr. 2020;20(1):141. doi:10.1186/s12887-020-02035-7

15. Yang EJ, Beck KM, Sekhon S, Bhutani T, Koo J. The impact of pediatric atopic dermatitis on families: a review. Pediatr Dermatol. 2019;36(1):66-71. doi:10.1111/pde.13727

16. Mitchell AE, Fraser JA, Morawska A, Ramsbotham J, Yates P. Parenting and childhood atopic dermatitis: a cross-sectional study of relationships between parenting behaviour, skin care management, and disease severity in young children. Int J Nurs Stud. 2016;64;72-85. doi:10.1016/j.ijnurstu.2016.09.016