As a dermatologist, it can be easy to fixate on a patient’s primary skin problem and overlook other related conditions, especially if they do not present overtly. Several comorbidities associated with atopic dermatitis (AD) fit this description well, which is why clinician screening for these states is vital. By gaining a better understanding of some of these underlying comorbidities, and integrating screening for them into regular clinical practice, dermatologists can more fully address every aspect in which a patient’s skin disease impacts their overall health and wellness, from physical symptoms to quality of life.
There are many known comorbidities of AD, but some might not be immediately apparent during patient exams because they occur at night, when the patient is in bed. “Sleep disorders are both a manifestation of AD and a comorbidity,” said Aaron Mark Drucker, MD, FAAD, a dermatologist at Women’s College Hospital in Toronto, Ontario, and researcher at Women’s College Research Institute in Toronto. “They can greatly impact a patient’s quality of life.” Dr Drucker gave a presentation about AD comorbidities at the 2019 Annual Meeting of the American Academy of Dermatology in Washington, DC, on Saturday, March 2.
Adults with AD have 3 times the rates of insomnia as the general population, and report a higher incidence of disordered sleep initiation and maintenance, regular daytime sleepiness and fatigue, and parasomnias compared with adults without AD.1 Similar effects have been found in children with the disease. Eleven percent of children with AD, and 22% with severe AD, experience impaired sleep 4 or more nights a week.2
The underlying pathogenic mechanisms driving these associations is not completely understood, though it is suspected that the itch-scratch cycle plays a role in both adults and children.2 Poor sleep duration and quality has been linked to a number of other health conditions in both children and adults, some of which are independent comorbidities of AD. Children with AD are more likely to be diagnosed with attention deficit/hyperactivity disorder (ADHD), for example, and have higher rates of conduct disorders, anxiety, and depression3-5 Adults with AD also experience higher rates of anxiety and depression compared with their AD-free counterparts, as well as poor overall health,1,4,6 Additionally, adults suffering from both AD and insomnia reported a greater number of doctor visits than those with either condition alone.1
Fortunately, research has also found that controlling AD, regardless of the treatment method or delivery system, can positively impact sleep as well.7-9 “As the disease improves, sleep improves as well,” said Dr Drucker. For this reason, he said, it is important for dermatologists to ask patients about sleep habits, including average duration and disruptions, during clinic visits. “How they respond can be a marker of overall disease activity and how well it is being controlled,” said Dr Drucker.
In general, he said, sleep disorders associated with AD will resolve on their own when the skin condition is controlled, and there is no need to pursue independent treatment for sleep problems unless those symptoms persist after the underlying dermatologic issues have been addressed. “In the event that sleep disorders are refractory to AD treatment, the patient may be referred to a sleep specialist,” said Dr Drucker.
AD has also been associated with several mental health conditions, including anxiety and depression, which require more in-depth screening by clinicians. “There is double the risk of depression among [adult] patients with AD compared to the general population,” said Dr Drucker. “There have been similar findings for anxiety disorders.” Children show an increased risk for both these mental health issues as well.10
Like many chronic diseases, AD can impair quality of life, decrease work performance and attendance, cause social embarrassment and incur financial strain due to medical costs. It is also associated with a number of other chronic diseases and conditions that can contribute to a deteriorating mental state—and potentially, to suicidal thoughts and self-harm.
Dr Drucker presented results of a study he coauthored, which found that among adult patients whose AD was classified as severe (meaning the patient had had 5 or more clinician visits for AD in the preceding 5 years), there is also an increase in suicide ideation.11 The double-matched case control study found that patients with persistent AD had a 22% increased risk of suicide.11 The same study found that two-thirds of patients who died from suicide had seen a physician in the month before their death, and 13% saw a physician for AD.11 “The significance of that is that there is an opportunity for intervention,” said Dr Drucker. Dermatologists may be in a unique position to do so.
Traditionally, however, dermatologists underrecognize depression and anxiety in patients.12 Simple standardized screening tools like the Patient Health Questionnaire-2 (PHQ-2) can be useful, but developing good patient rapport and discussing mental state should be integrated into regular clinic visits. “Start by just asking about their mood,” suggested Dr Drucker. “If the response causes concern, then ask if they’ve had thoughts of self-harm next.” Any patient who presents with signs of significant mental health distress should be assessed for suicide risk by the appropriate professionals. Patients who exhibit milder signs of anxiety and/or depression may need additional resources, and dermatologists should coordinate a treatment plan with the patient’s primary care doctor.
When it comes to chronic skin conditions with significant comorbidities that greatly impact quality of life for a patient, dermatologists can play a unique role in providing care beyond simply treating the obvious symptoms. Taking measures to screen patients with moderate to severe AD can yield much greater results.
1. Silverberg JI, Garg NK, Paller AS, Fishbein AB, Zee PC. Sleep disturbances in adults with eczema are associated with impaired overall health: a US population-based study. J Invest Dermatol. 2015;135(1):56-66. doi:10.1038/jid.2014.325
2. Camfferman D, Kennedy JD, Gold M, Martin AJ, Winwood P, Lushington K. Eczema, sleep, and behavior in children J Clin Sleep Med. 2010;6(6):581-588.
3. Schmitt J, Romanos M, Schmitt NM, Meurer M, Kirch W. Atopic eczema and attention-deficit/hyperactivity disorder in a population-based sample of children and adolescents. JAMA. 2009;301(7):724-726. doi:10.1001/jama.2009.136
4. Yaghmaie P, Koudelka CW, Simpson EL. Mental health comorbidity in patients with atopic dermatitis. J Allergy Clin Immunol.2013;131(2):428-433. doi:10.1016/j.jaci.2012.10.041
5. Slattery MJ, Essex MJ, Paletz EM, et al. Depression, anxiety, and dermatologic quality of life in adolescents with atopic dermatitis. J Allergy Clin Immunol. 2011;128(3):668-671. doi:10.1016/j.jaci.2011.05.003
6. Yang YW, Tseng KC, Chen YH, Yang JY. Associations among eczema, asthma, serum immunoglobulin E and depression in adults: a population-based study. Allergy. 2010;65(6):801-802. doi:10.1111/j.1398-9995.2009.02249.x
7. Berth-Jones J, Takwale A, Tan E, et al. Azathioprine in severe adult atopic dermatitis: a double-blind, placebo-controlled, crossover trial. Br J Dermatol. 2002;147(2):324-330.
8. Simpson EL, Gadkari A, Worm M, et al. Dupilumab therapy provides clinically meaningful improvement in patient-reported outcomes (PROs): A phase IIb, randomized, placebo-controlled, clinical trial in adult patients with moderate to severe atopic dermatitis (AD). J Am Acad Dermatol. 2016;75(3):506-515. doi:10.1016/j.jaad.2016.04.054
9. Guttman-Yassky E, Silverberg JL, Nemoto O, et al. Baricitinib in adult patients with moderate-to-severe atopic dermatitis: a phase 2 parallel, double-blinded, randomized placebo-controlled multiple-dose study [published online February 1, 2018]. J Am Acad Dermatol. doi:10.1016/j.jaad.2018.01.018
10. Rønnstad ATM, Halling-Overgaard AS, Hamann CR, Skov L, Egeberg A, Thyssen JP. Association of atopic dermatitis with depression, anxiety, and suicidal ideation in children and adults: A systematic review and meta-analysis. J Am Acad Dermatol. 2018;79(3):448-456.e30. doi:10.1016/j.jaad.2018.03.017
11. Drucker AM, Thiruchelvam D, Redelmeier DA. Eczema and subsequent suicide: a matched case-control study. BMJ Open. 2018;8(11):e023776. doi:10.1136/bmjopen-2018-023776
12. Dalgard FJ, Svensson A, Gieler et al. Dermatologists across Europe underestimate depression and anxiety: results from 3635 dermatological consultations. Br J Dermatol. 2018;179(2):464-470. doi:10.1111/bjd.16250