Atopic Dermatitis: More Than Skin Deep

This article discusses the impact of atopic dermatitis on mental health among pediatric patients and caregivers and the importance of integrated care to help alleviate the burden of this chronic disease.

Dr Liacia and Diaz

Figure 1. Drs Sasha Jaquez (right) and Lucia Diaz (left) work with children with atopic dermatitis.

Atopic dermatitis (AD) is a common chronic inflammatory and recurrent skin disease characterized by pruritus and skin dryness. Prevalence rates suggest that 10% to 20 % of children in the United States suffer from AD, with similar rates being seen across Europe and Asia.1-3 While AD is often diagnosed in early infancy, it places significant burden on patients and their caregivers throughout all stages of childhood and adolescence due to its chronic and relapsing course. Research has shown that common burdens of AD that affect the child, parents and siblings include sleep issues, lifestyle changes, social impacts, family activities, financial stress, and marital stress.4,5 

Burden of Disease 

Parents of children diagnosed with AD agree that the level of burden they experience while caring for a child with AD is not recognized or understood by the general public and this burden can become even greater when parents have been accused of child abuse or neglect.6 Furthermore, due to its non-life-threatening nature, families do not receive potentially useful education or psychosocial support further impacting stress and frustration.5

Along with family burden, children with AD are at an increased risk for experiencing or developing behavioral and emotional difficulties. Pouya Yaghmaie, MPH, and colleagues found strong associations between children diagnosed with AD and behavioral health diagnoses of attention deficit/hyperactivity disorder, depression, anxiety, conduct disorder, and autism. Furthermore, the probability of having a behavioral health diagnosis increased with AD severity.7 This suggests that children with AD might have an increased risk of developing behavioral health diagnoses and that those with more severe AD appear to have the greatest risk. As child behavioral problems increase, research has shown lower self-efficacy and less success (self-reported) in parents performing tasks necessary for AD management,10 including managing medication, managing eczema and symptoms, communicating with health care professionals, and managing challenges when caring for a child with eczema.11 

Previous research has also shown that child resistant treatment can be a significant problem for families with children who have AD. Resistant behavior includes kicking or screaming while trying to apply medication or moisturizers that may prompt parents to adopt coercive parenting strategies (ie, bribe, force) or reduce the frequency of therapy to avoid conflict, both of which may be counterproductive to successful long-term management and could be potentially damaging to the parent-child relationship.12 Results of these studies suggest that children with more profound behavioral difficulties are also likely to have more severe AD and may represent the highest risk group of children whose parents may struggle to manage the disease successfully.10

While some diagnosable behavioral health disorders have been observed in children with AD, even if not at a diagnosable level, many other children will experience decreases in quality of life (QoL), irritability, mood changes, sleep disturbances, lower self-esteem, and bullying.8 Children who experience
bullying are also at higher-risk of reporting psychosomatic complaints, such as loneliness, lower self-esteem, self-harm, suicidality, body dissatisfaction, and poor self-image, and these effects can persist into adulthood. More specifically, skin-related bullying has been linked to embarrassment, self-esteem, self-image, self-consciousness, and social exclusion.9 

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