In this podcast, Jonathan I. Silverberg, MD, PhD, MPH, associate professor of dermatology, medical social sciences, and preventive medicine at Northwestern Feinberg School of Medicine, discusses translating the latest evidence on comorbidities in atopic dermatitis into practice.
Hello, I’m Dr Jonathan Silverberg. I’m an associate professor of dermatology, medical social sciences, and preventative medicine at the Northwestern University Feinberg School of Medicine. Today, I’ll be discussing translating the latest evidence on comorbidities in atopic dermatitis into practice.
Several studies have shown associations between atopic dermatitis and a variety of different comorbidities. The most well‑established comorbidities are the atopic comorbidities such as asthma, hay fever, food allergies, and, more recently, the recognition of eosinophilic esophagitis as an atopic comorbidity as well.
These appear to be directly related to the severity of atopic dermatitis where more severe the skin disease, more severe the itch and the symptoms, overall, the higher the risk of these atopic comorbidities downstream potentially. There are a number of other comorbidities, particularly the mental health comorbidities, such as depression, anxiety, symptoms of inattentiveness.
Recent studies have shown that, not only are the rates of major depressive disorder and generalized anxiety disorder higher in atopic dermatitis patients but that this is not a random association. In fact, these are symptoms of depression and anxiety that track with the severity of the disease.
The more severe the atopic dermatitis, the higher the occurrence and the more severe the symptoms of depression and anxiety are. This is an area of further interest of trying to understand why this happens. But, these seem to be symptoms of atopic dermatitis per se.
There are a number of other comorbidities, particularly in the realm of cardiometabolic risk, cardiovascular risk factors, cardiovascular disease, obesity, hypertension, hyperlipidemia, diabetes, heart attack, stroke, congestive heart failure, etc. that have been shown in at least one study to be associated with atopic dermatitis.
This is an area that is still early in our understanding. Some studies have shown that these effects may be more indirect and related more toward things like smoking and poor lifestyle, whereas, other studies have shown direct effect between atopic dermatitis and these cardiovascular risk factors and events. We certainly need more studies to sort this out. It suggests that our patients with atopic dermatitis, particularly with moderate to severe disease, are in fact at higher risk for cardiovascular risks and events.
The first thing that the dermatologists need to recognize when translating these finding to clinical practice is to first recognize that they’re there. Some of the comorbidities are still early in our understanding. Maybe those are not the highest yield. Certainly, in the realm of the atopic comorbidities, the mental health comorbidities where we now have numerous meta‑analyses showing and confirming these associations. The dermatologist has to recognize that these are real and these are part of the broader impact of skin disease in our atopic dermatitis patients.
Part two is, what can the dermatologist actually do about these? The first thing is to recognize that, for many of these comorbidities, if we don’t treat those, if we don’t address those properly, that, ultimately, patients will be suffering with respect to their sleep, their quality of life, their everyday activities of daily living.
The same way that we in dermatology are trying to improve quality of life by addressing the skin issues, we need to at least be able to screen for some of these comorbidities and refer to the appropriate providers who can address these and properly manage these.
In terms of what tools can we use, in part, sometimes it can be open‑ended questions like, do you have asthma? Have you been wheezing more recently?
There are more structured tools that can be used like the asthma control test, or the ACQ6, and others that are more formal assessments that can be used. Open‑ended questions are a good starting place to understand that.
When you get into comorbidities such as mental health comorbidities, that’s where it gets very interesting. The same idea is true where if a patient is clinically depressed or clinically meets criteria for generalized anxiety disorder, then it’s important to make sure that those patients are properly evaluated and managed with the right mental healthcare provider.
On the flip side, many of those symptoms are a testament to the severity and the burden of the skin disease. These are things that, when asking questions about mental health, symptoms of depression, anxiety, if there are flags there, if there are patients who are experiencing symptoms of depression and anxiety, that should be a clue to the dermatologist that this skin disease is more severe than they may have realized.
They may need to step up treatment and incorporate those symptoms of depression and anxiety as a cue, as a trigger, a prompt to step up therapy.
What tools can be used? There are a number of different screening tools out there. We’ve recently published a study that validated the Hospital Anxiety and Depression Scale for assessing the mental health symptoms in atopic dermatitis.
There are other ones that are out there that can be used as well, patient health questionnaire, there’s PROMIS assessments that can be used, etc.
Screening for comorbidities is an area that we need more research into who are the optimal patients to be screened and which patients can we play the odds and not have to worry about too much.
For your average young, healthy patient who is otherwise thriving well, doing well, their disease is well‑controlled, that’s the type of patient that, certainly, we want to make sure that they’re up to date with all of their age‑appropriate cancer screenings. I wouldn’t necessarily advocate that that’s a patient we must screen more aggressively for.
On the flip side, when you have patients who are more severe, hence who have been on systemic immunosuppressants in the past which might increase the risk for malignancy, patients where there may be some potential underlying immunodeficiencies which might increase the risk for malignancy.
Particularly, patients where they may have later‑onset of disease where they may break out with some really severe pruritus, refractory disease, those are patients where we might be thinking more about potentially paraneoplastic process where the malignancy may even be somehow related to the worsening of their itch or the worsening of their atopic dermatitis. Particularly, we think about lymphoma in those cases but possibly solid organ malignancies as well.
For a number of the comorbidities, we already have a solid body of literature to show a strong association with atopic dermatitis, particularly for the atopic comorbidities and the mental health comorbidities.
The next generation of research needs to address that longitudinal piece—how these evolve over time, how these are impacted by different treatments, whether more aggressive control, tighter control of the skin disease and the symptoms could potentially prevent or modify the risk of developing these comorbidities, and of course, how do we best screen and manage these comorbidities in the atopic dermatitis patient population.
For the more novel comorbidities such as cardiovascular risk, or some of the neurologic or autoimmune comorbidities, even the malignancy comorbidities, we need a lot more studies, both cross‑sectional and longitudinal, to better understand that causality of association and whether or not atopic dermatitis truly leads to those comorbidities, and if so, how do we properly manage those, and screen for those, and prevent them.
Recent research has highlighted this concept of the systemic nature of atopic dermatitis, recognizing that it is a disease that manifests on the skin and manifests with skin signs and symptoms but that the impact of the disease goes well beyond the skin.
There’s systemic inflammation that occurs, which is highly related to atopic disease. There’s also a much broader impact on patients’ quality of life, which will have its impact in terms of mental health comorbidities, etc, and perhaps other mechanistic underpinnings that lead to these different comorbidities but recognizing that the broader impact of atopic dermatitis is not just skin deep.
Thank you for listening.
For more articles, visit the Centers of Excellence Atopic Dermatitis