Joy Wan, MD, MSCE is an instructor in the Department of Dermatology at the University of Pennsylvania and practices at Children's Hospital of Philadelphia. Her clinical and research expertise includes atopic dermatitis, psoriasis, and pediatric dermatoepidemiology. Dr Wan joined The Dermatologist to discuss her recent study, “Association of Atopic Dermatitis Severity With Learning Disability in Children”1, and share her insights on AD.
What was the reason you and your team conducted this study?
We did the study because we had found, in a previous study looking at US children on a population level2 , that there was an association between atopic dermatitis and learning disability. To our knowledge, that was the first body of work that really noted this potential connection.
Since that was a population-based study using data from the National Health Interview Survey, we didn't have a lot of additional data about atopic dermatitis, such as disease severity, in that cohort of kids.
As a follow-up to that, we wanted to do this study to really tease out the relationship between atopic dermatitis severity and the odds of learning disability. We hypothesized that atopic dermatitis was a contributing factor to learning problems, hence children who have more severe skin disease would be more likely to have learning problems than the kids who have less severe skin disease.
Your study found that AD severity was associated with a heightened risk of reported learning disability (LD). What is the significance of these findings?
In short, what we found was that, as the atopic dermatitis severity worsened, the odds of having learning disability increased. If you had moderate or severe disease, you were two to three times more likely to have learning disability compared to a child with clear or inactive atopic dermatitis.
This dose-response association is important because it suggests that atopic dermatitis, in and of itself, may be a driver of learning problems. More broadly, these findings support the growing notion that atopic dermatitis has many effects beyond just the skin, including impacts on mental health, learning, and perhaps also school functioning.
These associations are important for clinicians, as well as patients and families, to be aware of. The hope is that, down the line, we'll understand how to better intervene in the disease and to address some of these additional challenges that children with atopic dermatitis may experience. Before we can do that, we will need to further dissect the nature of the associations that we're observing between atopic dermatitis and learning disability.
Can you share what areas of future research are needed to better understand the relationship between AD and LD?
As I mentioned earlier, this is just one of the first studies to test whether there is this relationship. One of the limitations of our current study is that it's cross-sectional in nature, which means that we're evaluating atopic dermatitis severity and learning disability at the same time.
Thus, we still need to further evaluate the relative timing of these two conditions. Future studies that are prospective or longitudinal, where you might for example follow kids from an early age before they’ve developed any learning difficulties, would be needed to really understand the nature of timing between atopic dermatitis and learning disability.
Beyond that, we also need to understand the types of learning problems that are involved in children with atopic dermatitis because learning disability is a fairly broad diagnosis.
Direct evaluation of learning abilities is going to be really critical in future work. That would also overcome one of the limitations of this study which is that we relied on patient or family report of the child having been diagnosed with a learning disability by a health care practitioner.
It’s mentioned that LDs were diagnosed by a health care practitioner as reported by the patients and their caregivers. How should dermatologists work together with practitioners to determine whether an AD patient has a LD?
As specialists, we sometimes don't do the best jobs of thinking outside of our specialty and asking about symptoms that are beyond just the skin.
In the case of learning disabilities, even if we don't know how to directly assess a child for these conditions, knowing which types of providers we should refer our patients to if there is a concern is really important. For example, a child psychologist might be one type of colleague who would be able to directly evaluate for learning disabilities and then help the child or family access the necessary therapies or educational supports in school.
What clinical implications and considerations should dermatologists take from your study?
The first thing is an awareness that atopic dermatitis can have profound impacts beyond just the skin. In particular, there's a lot of emerging data to support that it impacts mood, sleep, and attention, for example. Our study results suggest that atopic dermatitis might also impact learning, particularly among children with more severe disease.
The clinical implication of this is to be mindful of that connection and to ask your patients about these things. In my practice, I often ask my patients with atopic dermatitis how the skin disease is impacting their day-to-day. How are they sleeping? How are they doing in school? Oftentimes, when you ask these questions, a lot of concerns that weren't previously brought up by the patients or their families become apparent simply because you've asked. If concerns are raised, it is then incumbent on us to make sure that they're appropriately addressed and referred to other specialists if needed.
References:
1. Wan J, Mitra N, Hooper SR, Hoffstad OJ, Margolis DJ. Association of Atopic Dermatitis Severity With Learning Disability in Children. JAMA Dermatol. Published online April 14, 2021;e210008. doi:10.1001/jamadermatol.2021.0008
2. Wan J, Shin DB, Gelfand JM. Association between atopic dermatitis and learning disability in children. J Allergy Clin Immunol Pract. 2020;8(8):2808-2810. doi:10.1016/j.jaip.2020.04.032
