Association of atopic dermatitis with depression, anxiety, and suicidal ideation in children and adults: A systematic review and meta-analysis

Estimated Frequency of Psychodermatologic Conditions in Alberta, Canada

BACKGROUND

Psychodermatologic disorders are difficult to identify and treat. Knowledge about the prevalence of these conditions in dermatological practice in Canada is scarce. This hampers our ability to address potential gaps and establish optimal care pathways.

OBJECTIVES

To provide an estimate of the frequencies of psychodermatologic conditions in dermatological practice in Alberta, Canada.

METHODS

Two administrative provincial databases were used to estimate the prevalence of potential psychodermatological conditions in Alberta from 2014 to 2018. Province-wide dermatology claims data were examined to extract relevant International Classification of Disease codes as available. Claims were linked with pharmacy dispensation data to identify patients who received at least 1 psychoactive medication within 90 days of the dermatology claim.

RESULTS

Of 243 963 patients identified, 28.6% had received at least 1 psychotropic medication (mean age: 47.9 years; 67.5% female). Rates of concurrent psychotropic medications were highest for pruritus and related conditions (46.7%), followed by urticaria (44.5%) and hyperhidrosis (32.8%). Among patients with psychotropic medications, rates of antidepressants were highest (56.3%), followed by anxiolytics (37.1%). Across billing codes, besides hyperhidrosis (71.2%), diseases of hair (61.4%) and psoriasis (59.1%) had the highest rates of antidepressant dispensations. Patients with atopic dermatitis had the highest rates for anxiolytic prescriptions (54.3%).

CONCLUSION

In a 5-year window, more than a quarter of the identified dermatology patients in Alberta received at least 1 psychotropic medication, pointing to high rates of potential psychodermatologic conditions and/or concurrent mental health issues in dermatology. Diagnostic and care pathways should include a multidisciplinary approach to better identify and treat these conditions.

The Effect and Mechanism of Adverse Childhood Experience on Suicide Ideation in Young Cancer Patients During Coronavirus Disease 2019 (COVID-19) Pandemic

Background and Aim

Coronavirus disease 2019 (COVID-19) is currently prevalent worldwide. This research aimed to explore the effect of adverse childhood experience (ACE) on suicide ideation in young cancer patients during the COVID-19 pandemic. Self-reported questionnaires analyzed the mediating effects of sleep quality, anxiety symptoms, and inflammatory conditions between ACE and suicide ideation.

Materials and Methods

A total of 197 young cancer patients (age 18–40) completed questionnaires and a blood test. Correlation analysis and structural equation model were used to explore the relationships between ACE, sleep quality, anxiety symptom, serum C-reactive protein (CRP) levels and suicide ideation. The mediating roles of sleep quality, anxiety symptoms, and CRP levels on the influence of ACE on suicide ideation were explored.

Results

ACE was positively related to anxiety symptoms, CRP levels, and suicide ideation, and negatively related to sleep quality. Anxiety symptoms and CRP levels were positively related to suicide ideation, while sleep quality was negatively related to suicide ideation. Anxiety symptoms were positively related to CRP levels but negatively related to sleep quality. From these results, we found ACE affected suicide ideation directly and was mediated by roles sleep quality, anxiety symptom and CRP.

Conclusion

ACE not only directly affected suicide ideation but also affected suicide ideation through sleep quality, anxiety symptoms, and inflammatory conditions in young cancer patients during the COVID-19 pandemic. Therefore, targeted intervention and help for cancer patients from the perspective of ACE should be put into practice.

Real-world persistence with dupilumab among adults with atopic dermatitis

BACKGROUND

The real-world persistence with dupilumab therapy for atopic dermatitis (AD) is unknown.

OBJECTIVE

To characterize adults with AD who initiated dupilumab and evaluate persistence with dupilumab therapy.

METHODS

This retrospective cohort study used the IBM MarketScan Commercial and Medicare database. Adults with AD who initiated dupilumab (first dispensation = index date) between March 28, 2017, and March 31, 2018, were identified and followed up until September 30, 2018, or disenrollment. Twelve months of continuous preindex enrollment were required to characterize baseline treatment history and comorbidities. Kaplan-Meier analysis was used to estimate dupilumab persistence at 6 and 12 months, assuming a 14-day injection frequency and a 30-day grace period.

RESULTS

A total of 1963 adults were identified who initiated dupilumab (mean [SD] age 42.1 [15.7] years; 50.7% women; 49.8% with ≥1 atopic comorbidity). Baseline AD treatments included topical corticosteroids (81.6%), systemic corticosteroids (72.5%), and systemic immunosuppressants (22.8%). Dupilumab persistence (95% confidence interval) at 6 and 12 months was 91.9% (90.7%-93.2%) and 77.3% (75.0%-79.7%), respectively. Among 329 patients who discontinued dupilumab, the risk of reinitiation was 78.8% (95% confidence interval: 75.8%-81.7%) within an average of 4 months.

CONCLUSION

Dupilumab persistence at 12 months was high, suggesting patient satisfaction with effectiveness, tolerability, and treatment regimen.

Efficacy and safety of abrocitinib in adults and adolescents with moderate-to-severe atopic dermatitis (JADE MONO-1): a multicentre, double-blind, randomised, placebo-controlled, phase 3 trial

BACKGROUND

Abrocitinib, an oral selective Janus kinase 1 inhibitor, was effective and well tolerated in adults with moderate-to-severe atopic dermatitis in a phase 2b trial. We aimed to assess the efficacy and safety of abrocitinib monotherapy in adolescents and adults with moderate-to-severe atopic dermatitis.

METHODS

In this multicentre, double-blind, randomised phase 3 trial (JADE MONO-1), patients (aged ≥12 years) with moderate-to-severe atopic dermatitis (Investigator Global Assessment score ≥3, Eczema Area and Severity Index [EASI] score ≥16, percentage of body surface area affected ≥10%, and Peak Pruritus Numerical Rating Scale score ≥4) with a bodyweight of 40 kg or more, were enrolled at 69 sites in Australia, Canada, Europe, and the USA. Patients were randomly assigned (2:2:1) to oral abrocitinib 100 mg, abrocitinib 200 mg, or placebo once daily for 12 weeks. Randomisation was done using an interactive response technology system, stratified by baseline disease severity and age. Patients, investigators, and the funder of the study were masked to study treatment. The coprimary endpoints were the proportion of patients who had achieved an Investigator Global Assessment response (score of 0 [clear] or 1 [almost clear] with a ≥2-grade improvement from baseline), and the proportion of patients who achieved at least a 75% improvement in EASI score from baseline (EASI-75) score, both assessed at week 12. Efficacy was assessed in the full analysis set, which included all randomised patients who received at least one dose of study medication. Safety was assessed in all randomised patients. This study is registered with ClinicalTrials.gov, NCT03349060.

FINDINGS

Between Dec 7, 2017, and March 26, 2019, 387 patients were enrolled: 156 were assigned to abrocitinib 100 mg, 154 to abrocitinib 200 mg, and 77 to placebo. All enrolled patients received at least one dose of study treatment and thus were evaluable for 12-week efficacy. Of the patients with available data for the coprimary endpoints at week 12, the proportion of patients who had achieved an Investigator Global Assessment response was significantly higher in the abrocitinib 100 mg group than in the placebo group (37 [24%] of 156 patients vs six [8%] of 76 patients; p=0·0037) and in the abrocitinib 200 mg group compared with the placebo group (67 [44%] of 153 patients vs six [8%] of 76 patients; p<0·0001). Of the patients with available data for the coprimary endpoints at week 12, compared with the placebo group, the proportion of patients who had achieved an EASI-75 response was significantly higher in the abrocitinib 100 mg group (62 [40%] of 156 patients vs nine [12%] of 76 patients; p<0·0001) and abrocitinib 200 mg group (96 [63%] of 153 patients vs nine [12%] of 76 patients; p<0·0001). Adverse events were reported in 108 (69%) of 156 patients in the abrocitinib 100 mg group, 120 (78%) of 154 patients in the abrocitinib 200 mg group, and 44 (57%) of 77 patients in the placebo group. Serious adverse events were reported in five (3%) of 156 patients in the abrocitinib 100 mg group, five (3%) of 154 patients in the abrocitinib 200 mg group, and three (4%) of 77 patients in the placebo group. No treatment-related deaths were reported.

INTERPRETATION

Monotherapy with oral abrocitinib once daily was effective and well tolerated in adolescents and adults with moderate-to-severe atopic dermatitis.

FUNDING

Pfizer.

Histoire naturelle de la dermatite atopique

Atopic dermatitis (AD) is a common frequent chronic inflammatory skin disease which begins frequently in infancy. The clinical expression of AD is a recurrent eczema on a dry skin. AD is a multifactorial disease characterized by two linked abnormalities: a skin barrier defect and a cellular inflammation, with type-2 main components. However, the pathophysiology of AD is not as simple as this description looks like. In this review, we will present a synthesis of current knowledge on natural history of AD and the involved factors, in order to clarify AD care. The evolution of AD is associated with many atopic comorbidities, following the "atopic march" scheme: IgE-mediated food allergy, allergic asthma and rhinitis occurring classically after AD. In fact, this is rarely the case, but the atopic march seems to be associated with AD severity. AD has also many neuropsychological complications which are essential to be detected. Other factors could influence the natural history of AD: genetic mutations on different genes (proteins of skin barrier, innate and adaptive immunity pathways), skin dysbiosis with colonization by Staphylococcus aureus, sensitization against environmental proteins. AD treatment is based on the restauration of the skin barrier using emollients and on anti-inflammatory drugs (notably topical corticosteroids) during the inflammatory flares. It is not recommended to treat the skin colonization by S. aureus, excepted in case of skin infection. The probiotics have no efficiency as curative treatment of AD, but could have an interest for the primary prevention, especially in at-risk populations. © 2019 Elsevier Masson SAS. All rights reserved.

Comorbidités de la dermatite atopique

Atopic dermatitis is associated with an increased risk of asthma (10 to 30% according to age), allergic rhinitis and conjunctivitis and food allergy. Other comorbidiies are globally lest frequent than in psoriasis. There is no increased risk of solid cancer. Smoking is a major confounding factor that has to be taken into account. Obesity and metabolic syndrome are more frequent and there is a moderately increased cardiovascular risk in severe forms of atopic dermatitis. There is a clear-cut increased risk of vitiligo and alopecia areata and a lower risk of other auto-immune diseases, including type I diabetes in children. There is a higher risk of cutaneous but not extra-cutaneous bacterial and viral infections, and increased frequency of contact dermatitis and urticaria. Severe atopic dermatitis is associated with psychiatric comorbidities, like attention disorders/hyperactivity, depression and suicidal ideas. © 2019 Elsevier Masson SAS. All rights reserved.

Biologics for Allergic Dermatologic Diseases

PURPOSE OF REVIEW

Atopic dermatitis (AD), chronic spontaneous urticaria (CSU), and allergic contact dermatitis (ACD) represent three important allergic dermatoses with many unmet therapeutic needs. The development of biologic agents has opened the door to both new treatment options and improved understanding of the underlying pathophysiology, both shared and unique for these entities. With several FDA-approved medications available and many more in development, the biologic revolution has begun for allergic dermatoses.

RECENT FINDINGS

This is a narrative review on the current state of pathomechanisms and appropriately targeted biologic agents for these three common allergic skin conditions. The importance of Th2 inflammation and the effect of inflammatory cytokines on the skin barrier may help explain the impressive efficacy of biologic agents, while maintaining relative safety. While some of the biologic agents show efficacy across multiple allergic dermatoses, more often it seems these more targeted pathways show accordingly precise efficacy. However, in each disease, multiple agents hold promise, and may be differentiated by safety and adverse effect profile rather than simply by efficacy. New understanding of the pathogenesis of the allergic dermatoses has ushered in a new era of biologic therapies. Competing mechanisms and molecules will continue to be developed and vetted in trials with hopes of continuously refined precision therapies with optimized safety and efficacy profiles.

Baseline characteristics, disease severity and treatment history of patients with atopic dermatitis included in the German AD Registry TREATgermany

BACKGROUND

The Atopic Dermatitis (AD) TREATgermany registry was initiated by the German Society for Dermatology (DDG) in 2011 to evaluate the 'real-life' situation of health care for patients with AD.

OBJECTIVES

Interim data analysis on baseline characteristics as well as current and prescribed systemic treatments of the TREATgermany registry patients.

METHODS

Patients (≥18 years) with moderate-to-severe AD [objective (o)SCORAD > 20], or with current or previous anti-inflammatory systemic treatment for AD within 24 months, were included and are followed up over at least 24 months. To assess clinical signs, the eczema area severity index (EASI, 0-72), the oSCORAD (0-83) and the Investigator Global Assessment (IGA; 6-point scale) were used. The disease severity was globally scored by the patients [Patient Global Assessment (PGA); six-step Likert scale]. Disease symptoms were assessed by the patient-oriented eczema measure (POEM, 0-28) and numeric rating scales (NRS, 0-10). Health-related quality of life was measured using the dermatological life quality index (DLQI, 0-30).

RESULTS

A total of 612 patients were recruited across 32 sites between 06/2016 and 01/2019 (mean age: 42.6 ± 14.2 years; mean oSCORAD: 40.8 ± 16.3). The mean POEM score was 16.3 ± 7.5. Pruritus was rated highest among subjective symptoms (NRS: 5.4 ± 2.7). The mean DLQI value was 11.3 ± 7.5. The frequency of arterial hypertension was lower (20.8%) compared with the general population, whilst this was higher for depression (10%). More than 60% of the patients had received systemic glucocorticosteroids, and 36.8% had received cyclosporine A prior to inclusion. Dupilumab was the leading substance documented as either 'current' (12.1%) or 'prescribed' (31.4%) at baseline.

CONCLUSIONS

These 'real-life' data clearly demonstrate the substantial disease burden. Most of TREATgermany patients were already treated with or prescribed dupilumab at baseline. Moreover, current findings indicate the urgent need for further alternative agents in order to achieve a perceptible improvement of quality of life of patients with moderate-to-severe AD.

Prevalence and Comorbidity of Atopic Dermatitis in Children: A Large-Scale Population Study Based on Real-World Data

This study aimed at exploring atopic dermatitis (AD) prevalence in children and exhaustively analyzing their comorbidity. We conducted a descriptive analysis of their socio-demographic and comorbidity characteristics in the EpiChron Cohort (Aragón, Spain). Adjusted odds ratios (OR) were calculated for each comorbidity using logistic regression models. In total, 33,591 children had a diagnosis of AD, resulting in an overall prevalence of 15.5%. AD prevalence was higher in girls compared to boys, in 3–9-year-olds compared to children of other ages, and in Spanish children compared to those of other nationalities. Multimorbidity was present in 43% of children, with the most frequent chronic comorbidities being asthma (13.1%), psychosocial disorders (7.9%), and visual impairment (7.8%). Many diseases were, regardless of their prevalence, statistically associated with AD. The strongest associations (odds ratio (OR) (95% confidence interval (CI))) were found in asthma (2.10 (2.02–2.17)), allergic rhinitis (2.00 (1.91–2.10)), and irritable bowel syndrome (1.90 (1.56–2.31)). A better understanding of the array of comorbidities associated with AD in children might help improve their clinical management. Future longitudinal studies are encouraged to shed light on the potential underlying pathophysiological mechanisms involved in the identified associations.

Diagnosis and management of moderate to severe atopic dermatitis in adolescents. A Consensus by the Italian Society of Dermatology and Venereology (SIDeMaST), the Italian Association of Hospital Dermatologists and Public Health (ADOI), the Italian Association of Hospital and Territorial Allergists and Immunologists (AAIITO), the Italian Society of Allergy, Asthma and Clinical Immunology (SIAAIC), the Italian Society of Pediatric Allergy and Immunology (SIAIP), the Italian Society of Allergological, Occupational and Environmental Dermatology (SIDAPA), and the Italian Society of Pediatric Dermatology (SIDerP)

Atopic dermatitis (AD) is a chronic inflammatory disease with increasing global incidence, which has a multifactorial pathogenesis and a variable expressivity. Clinical features of AD are different in adults compared to children, but it is well recognized the substantial impact of the disease on patients' quality of life at any age. Indeed, little is known about AD in adolescence, a period of life generally associated with high psychological burden and vulnerability to depression. Guidelines for the management of AD are available for both children and adults but specific guidelines for the diagnosis and treatment of AD in adolescents are lacking. Seven Italian scientific societies of dermatologists, allergists, and pediatric allergists joined in a specific meeting to provide practical guidance for the diagnosis and management of moderate-to-severe adolescent AD suitable for the Italian clinical practice. Through a modified Delphi procedure, consensus was reached by 59 Italian experts in the management of AD on 20 statements covering five areas of interest about adolescent AD, including disease complexity, burden and social impact, diagnosis and definition of severity, current treatments, and new biologic therapies. This paper reports recommendations for the diagnosis and management of AD specifically in adolescents, pointing out some peculiar clinical features and focusing on the choice of medications. Dupilumab, the first biologic approved for the treatment of adolescents with AD, represents a useful treatment option due to its efficacy and reassuring safety profile.

Disease Severity Is Associated with Alexithymia in Patients with Atopic Dermatitis

BACKGROUND

Atopic dermatitis (AD) is a chronic inflammatory skin disorder that is associated with higher rates of psychological disorders, but limited evidence supported the association with alexithymia, a psychoaffective dysfunction.

OBJECTIVES

This study was aimed to investigate the occurrence of alexithymia in AD patients, compared to healthy subjects.

METHODS

This cross-sectional study assessed AD severity by the Eczema Area and Severity Index (EASI) score, sleeplessness and itch by a numeric rating scale (NRS), and alexithymia by the 20-item Toronto Alexithymia Scale (TAS-20) score. The association between disease characteristics and alexithymia was evaluated through several logistic regression models.

RESULTS

202 AD patients and 240 healthy subjects were included in this study. The alexithymic personality trait (TAS-20 ≥51) was more frequently observed among AD patients compared to the control group (62.4% [126/202] vs. 29.2% [70/240], p < 0.0001). In particular, alexithymia (TAS-20 score ≥61) was detected in a significantly higher number of AD patients than in the controls (27.7% [56/202] vs. 7.5% [18/240]; p < 0.0001), whereas borderline alexithymia was detected in 34.6% (70/202) of AD patients compared to 21.7% of healthy controls. Alexithymia was more common among severe AD patients (43.6%) compared to mild AD patients (15.6%) and correlated with itch intensity and sleep disturbances. Among clinical variables, ordered logistic regression analyses revealed disease severity as predictor of alexithymia. Indeed, univariate analysis showed EASI score, sleep NRS, and itch NRS being significantly associated with alexithymia, while a multivariate model identified increased EASI score values as predicting factor.

CONCLUSION

This study described alexithymia in AD patients correlating its occurrence with clinical AD severity markers (EASI score, itch, and sleeplessness) and identifying the increase in EASI score as predicting factor.

Consensus on the Clinical Approach to Moderate-to-Severe Atopic Dermatitis in Spain: A Delphi Survey

BACKGROUND

The purpose of this study was to gather information on the current assessment and management of patients with moderate-to-severe AD in routine daily practice.

METHODS

A cross-sectional two-round Delphi survey with the participation of dermatologists and allergologists throughout Spain was conducted. They completed a 46-item questionnaire, and consensus was defined when responses of ≥80% of participants coincided in the categories of a 5-point Likert scale for that item.

RESULTS

A total of 105 specialists (aged 40-59 years) completed the two rounds. Participants agreed regarding the consideration of AD as a multifaceted disease and the differences in clinical presentation of AD according to the patient's age. It is recommendable to perform a skin biopsy to exclude early stage T-cell cutaneous lymphoma, psoriasis, or dermatitis herpetiformis, among others (99.1%). Also, consensus was reached regarding the use of the SCORAD index to quantify the severity of the disease (86.7%), the use of wet wraps to increase the effect of topical corticosteroids (90.4%), the usefulness of proactive treatment during follow-up (85.6%) and tacrolimus ointment (91.2%) to reduce new flares, and the fact that crisaborole is not the treatment of choice for severe AD (92.4%). AD was not considered a contraindication for immunotherapy in patients with allergic respiratory diseases (92.4%). In patients with severe AD, the use of immune response modifier drugs (97.6%) or phototherapy (92.8%) does not sufficiently cover their treatment needs. Consensus was also obtained regarding the role of the new biologic drugs (93.6%) targeting cytokines involved in the Th2 inflammatory pathway (92.0%) and the potential role of dupilumab as first-line treatment (90.4%) in moderate-to-severe AD patients.

CONCLUSION

This study contributes a reference framework to the care of AD patients. There is no diagnostic test or biomarkers to direct treatment or to assess the severity of the disease, and many therapeutic challenges remain.

Recent developments and advances in atopic dermatitis and food allergy

This review highlights recent advances in atopic dermatitis (AD) and food allergy (FA), particularly on molecular mechanisms and disease endotypes, recent developments in global strategies for the management of patients, pipeline for future treatments, primary and secondary prevention and psychosocial aspects. During the recent years, there has been major advances in personalized/precision medicine linked to better understanding of disease pathophysiology and precision treatment options of AD. A greater understanding of the molecular and cellular mechanisms of AD through substantial progress in epidemiology, genetics, skin immunology and psychological aspects resulted in advancements in the precision management of AD. However, the implementation of precision medicine in the management of AD still requires the validation of reliable biomarkers, which will provide more tailored management, starting from prevention strategies towards targeted therapies for more severe diseases. Cutaneous exposure to food via defective barriers is an important route of sensitization to food allergens. Studies on the role of the skin barrier genes demonstrated their association with the development of IgE-mediated FA, and suggest novel prevention and treatment strategies for type 2 diseases in general because of their link to barrier defects not only in AD and FA, but also in asthma, chronic rhinosinusitis, allergic rhinitis and inflammatory bowel disease. The development of more accurate diagnostic tools, biomarkers for early prediction, and innovative solutions require a better understanding of molecular mechanisms and the pathophysiology of FA. Based on these developments, this review provides an overview of novel developments and advances in AD and FA, which are reported particularly during the last two years.

Association of atopic dermatitis with suicide risk among 788,411 adolescents: A Korean cross-sectional study

BACKGROUND

Atopic dermatitis (AD) is known to negatively influence the mental health of patients. However, only a few studies have explored the influencing factors for psychiatric problems among adolescents with AD.

OBJECTIVE

To assess the association of AD and suicidal behaviors among adolescents by analyzing data from the 3rd through the 13th annual Korean Youth Risk Behavior Web-based Surveys (completed from 2007 to 2017).

METHODS

Survey data were obtained from a stratified, multistage, clustered sample. Students self-reported AD if they had received a diagnosis of AD by a physician. Influencing factors for suicidal behaviors were tested by logistic regression models.

RESULTS

A total of 788,411 adolescents completed the survey. The proportion of participants with AD was 22.2%. Those reporting suicide ideation and suicide attempts were 19.0%, and 4.5%, respectively. Compared with adolescents without AD, those with AD were more likely to be female, to skip breakfast less frequently, to exercise less frequently, to drink less alcohol, and to not be current smokers and were statistically significantly more likely to have negative mental health states. In the multivariable model, perceived unhappiness and suicidal ideation were the strongest influencing factors for suicidal ideation (adjusted odds ratio, 4.90; 95% CI, 4.31-5.57) and for suicidal attempts (adjusted odds ratio, 48.01; 95% CI, 42.69-53.09), respectively.

CONCLUSION

Adolescents with AD had a meaningful prevalence of suicidal behaviors. Although further research is needed to clarify this association, adolescents with AD with influencing factors for negative mental health state may need intervention from practitioners who use a multidisciplinary team approach to prevent suicide.

Protocol for a prospective, observational, longitudinal study in paediatric patients with moderate-to-severe atopic dermatitis (PEDISTAD): study objectives, design and methodology

INTRODUCTION

Atopic dermatitis (AD) is a chronic inflammatory skin disease often associated with atopic comorbidities and has significant impact on children and their families. There is a lack of robust and longitudinal long-term data on disease characteristics and typical clinical practice with currently available treatments in children with moderate-to-severe AD. Hence, an observational study is needed to evaluate AD characteristics and progression in paediatric patients with moderate-to-severe AD.

METHODS AND ANALYSIS

Pediatric Study in Atopic Dermatitis (PEDISTAD) is a prospective, observational, longitudinal study in paediatric patients with moderate-to-severe AD who are currently receiving systemic or topical treatment and whose disease is not adequately controlled by topical prescription therapies or for whom those therapies are not medically advisable. 1300 children at 100-150 sites in approximately 20 countries worldwide will be enrolled and followed for 5 years. AD therapy is at the discretion of the investigator. Data collected will include: AD disease characteristics and comorbidities; current therapy for AD and initiation of new treatments/changes in current treatment; patient-reported/caregiver-reported outcomes; days missed from school/work for the patient/caregiver; healthcare professional visits; safety and biomarkers.

ETHICS AND DISSEMINATION

This study is conducted in accordance with the principles established by the 18th World Medical Assembly and all subsequent amendments and the guidelines for Good Epidemiology Practice. Each individual country assures that ethics approval has been received and local regulatory requirements are met. Ethics approval has been obtained in all countries currently participating in PEDISTAD. Study data will be disseminated in manuscripts submitted to peer-reviewed medical journals as well as in abstracts submitted to congresses and in the resulting posters and presentations.

TRIAL REGISTRATION NUMBER

NCT03687359; pre-results.

Depression, anxiety and quality of life in subjects with atopic eczema in a population-based cross-sectional study in Germany

BACKGROUND

Atopic eczema (AE) may be associated with several mental health problems. In Germany, existing data from selected patient cohorts may lead to misestimation of the problem.

OBJECTIVES

We aimed to cross-sectionally determine associations of AE with depression, anxiety, quality of life (QoL) and social interactions in subjects from the population-based LIFE-Adult-Study.

METHODS

Subjects underwent standardized interviews (medical history) and answered standardized questionnaires [Centre of Epidemiologic studies-Depression scale (CES-D), Generalized Anxiety Disorder (GAD-7), Lubben Social Network Scale (LSNS), Short Form Health Survey (SF-8)]. We compared data from subjects with AE with those from subjects with selected other chronic/disabling diseases (cardiovascular, diabetes, cancer) and adjusted for selected sociodemographic parameters. Multivariate binary logistic regression was used for categorical variables, linear regression for continuous variables.

RESULTS

Out of 9104 adults included (57% female, median age 54 years), 372 (4.1%) had a history of AE. Compared with controls, subjects with AE showed higher scores for depressive symptoms (9.3% vs. 6.3%; P < 0.001) and anxiety (8.4% vs. 5.6%, P < 0.001). Odds ratio (OR) was 1.5 [CI 1.0; 2.3] (P = 0.031) for depression, which was comparable to OR in patients with a history of cancer (OR 1.6 [1-2.3], P = 0.001. OR for anxiety in AE was 1.5 [1.0; 2.2], P < 0.049, which was slightly higher than in diabetes mellitus (OR 1.2) and stroke (OR 1.4). Other than in diabetes and/or stroke, we did not find a significant association between AE and social isolation. QoL scores were lower in AE than in controls (mean 46.9 vs. 48.0, P < 0.001 for physical and 50.6 vs. 52.5, P < 0.001 for mental components).

CONCLUSIONS

Subjects with AE showed higher values for depression and anxiety as well as lower QoL scores compared to controls. With regard to depression, odds in AE and cancer were hardly different. Medical care of AE patients should therefore include mental health evaluation and treatment if indicated.

The patient-reported disease burden in adults with atopic dermatitis: a cross-sectional study in Europe and Canada

Background

Cross‐sectional data on patient burden in adults with atopic dermatitis (AD) from real‐world clinical practice are limited.

Objective

This study compared patient‐reported burden associated with adult AD across severity levels from clinical practices in Canada and Europe.

Methods

This study included adults (18–65 years) diagnosed with AD by dermatologists, general practitioners or allergists. Participants categorized as mild (n = 547; 37.3%), moderate (n = 520; 35.4%) or severe (n = 400; 27.3%) based on Investigator's Global Assessment completed a questionnaire that included pruritus and pain numerical rating scales, Patient‐Oriented‐Scoring of Atopic Dermatitis (PO‐SCORAD) itch and sleep visual analogue scales, Dermatology Life Quality Index (DLQI), and the Hospital Anxiety and Depression Scale (HADS). Participants were also stratified by inadequate efficacy/intolerance/contraindication to cyclosporine [Cyclo; n = 62 (4 mild, 18 moderate, 40 severe)] and any systemic immunomodulatory agent [IMM; n = 104 (13 mild, 31 moderate, 60 severe)] and compared with the severe group excluding participants identified as Cyclo/IMM.

Results

Age was similar across severity groups; the proportion of women was higher in the mild group relative to severe (61.2% vs. 50.5%; P < 0.001). Compared with moderate and mild, participants with severe AD had more comorbidities, higher itch and pain severity, worse sleep and higher levels of anxiety and depression (all P < 0.001). Mean ± SD DLQI score among participants with severe AD (16.2 ± 6.9) showed a large effect on quality of life that was higher than those with moderate (10.2 ± 6.3) and mild (5.5 ± 4.9) (both P < 0.001). The burden among Cyclo and IMM subgroups was generally similar to that of participants with severe AD.

Conclusions

Adults with AD reported a substantial burden across multiple domains that was significantly higher in those with severe disease. The burden among participants in the Cyclo/IMM subgroups was similar to those with severe AD.

Atopic Eczema in Adulthood and Risk of Depression and Anxiety: A Population-Based Cohort Study

BACKGROUND

Atopic eczema is a common and debilitating condition associated with depression and anxiety, but the nature of this association remains unclear.

OBJECTIVE

To explore the temporal relationship between atopic eczema and new depression/anxiety.

METHODS

This matched cohort study used routinely collected data from the UK Clinical Practice Research Datalink, linked to hospital admissions data. We identified adults with atopic eczema (1998-2016) using a validated algorithm, and up to 5 individuals without atopic eczema matched on date of diagnosis, age, sex, and general practice. We estimated the hazard ratio (HR) for new depression/anxiety using stratified Cox regression to account for age, sex, calendar period, Index of Multiple Deprivation, glucocorticoid treatment, obesity, smoking, and harmful alcohol use.

RESULTS

We identified 526,808 adults with atopic eczema who were matched to 2,569,030 without. Atopic eczema was associated with increased incidence of new depression (HR, 1.14; 99% CI, 1.12-1.16) and anxiety (HR, 1.17; 99% CI, 1.14-1.19). We observed a stronger effect of atopic eczema on depression with increasing atopic eczema severity (HR [99% CI] compared with no atopic eczema: mild, 1.10 [1.08-1.13]; moderate, 1.19 [1.15-1.23]; and severe, 1.26 [1.17-1.37]). A dose-response association, however, was less apparent for new anxiety diagnosis (HR [99% CI] compared with no atopic eczema: mild, 1.14 [1.11-1.18]; moderate, 1.21 [1.17-1.26]; and severe, 1.15; [1.05-1.25]).

CONCLUSIONS

Adults with atopic eczema are more likely to develop new depression and anxiety. For depression, we observed a dose-response relationship with atopic eczema severity.

Atopic Dermatitis in Adults

Atopic dermatitis (AD) was once thought to be a benign childhood disease that remitted with increasing age. However, recent studies have transformed the understanding of AD, particularly in adult patients. AD is common in adults and can lead to substantial disability by negatively affecting sleep, mental health, and quality of life. There seem to be different genetic, immunologic, and epidemiologic risk factors for AD in adults than in children. This article examines the pathophysiology, epidemiology, heterogeneous clinical presentation, burden, diagnosis, and treatment of adult AD.

Maternal Depression and Atopic Dermatitis in American Children and Adolescents

Atopic dermatitis (AD) is a chronic, inflammatory skin disease associated with considerable burden and mental health symptoms. We sought to determine the association of maternal depression in the postpartum period and maternal and paternal depression in later childhood with AD prevalence and persistence in US children. Data were analyzed from the Fragile Families and Child Wellbeing Study, a prospective cohort study of 4898 children born in 20 metropolitan US cities. History of postpartum depression was associated with childhood AD overall (multivariable logistic regression; adjusted odds ratio [aOR], 1.32; 95% confidence interval [CI], 1.06-1.64), and particularly at ages 5 years (aOR, 1.34; 95% CI, 1.04-1.73) and 9 years (aOR, 1.37; 95% CI, 1.10-1.70). Postpartum depression was associated with more persistent AD (present at 2 years: aOR, 1.58; 95% CI, 1.12-2.22; 3 years: aOR, 1.73; 95% CI, 1.15-2.60). Maternal depression in the past year was associated with significantly higher odds of AD at age 5 years (aOR, 1.54; 95% CI, 1.20-1.99), 9 years (aOR, 1.36; 95% CI, 1.10-1.71), and 15 years (aOR, 1.43; 95% CI, 1.13-1.80). Maternal depression was associated with higher odds of AD during 1 year (aOR, 1.50; 95% CI, 1.16-1.94), 2 years (aOR, 1.60; 95% CI, 1.16-2.19), or all 3 years of interviews (aOR, 1.61; 95% CI, 1.06-2.45). In conclusion, maternal depression in the postpartum period and beyond is associated with AD throughout childhood and adolescence.

Associations of eczema phenotypes with emotional and behavioural problems from birth until school age. The Generation R Study

Background

Eczema phenotypes and emotional and behavioural problems are highly prevalent in childhood, but their mutual relationship is not fully clear.

Objectives

To examine the associations of eczema phenotypes with school‐age emotional and behavioural problems, and the bidirectional associations of eczema and emotional and behavioural problems from birth until 10 years.

Methods

This study among 5265 individuals was embedded in a prospective population‐based cohort study. Never, early transient, mid‐transient, late transient and persistent eczema phenotypes were identified based on parent‐reported, physician‐diagnosed eczema from age 6 months until 10 years. Emotional (internalizing) and behavioural (externalizing) problems were measured repeatedly using the Child Behavior Checklist from age 1·5 to 10 years. Cross‐lagged models were applied for bidirectional analyses.

Results

All eczema phenotypes were associated with more internalizing problems and attention problems at age 10 years, compared with never having eczema: range of Z‐score differences 0·14 [95% confidence interval (CI) 0·01–0·27] to 0·39 (95% CI 0·18–0·60). Children with early transient eczema had more aggressive behaviour symptoms at age 10 years (Z = 0·16, 95% CI 0·05–0·27). Bidirectional analysis showed that eczema at 0–2 years was associated with more internalizing and externalizing problems at ages 3–6 and 10 years, while, inversely, only internalizing problems at 0–2 years were associated with an increased risk of eczema at age 10 years.

Conclusions

Eczema phenotypes are very modestly associated with more somatic symptoms and attention problems at school age. Early transient eczema is associated with more aggressive behaviour symptoms. Directional effects seem to occur from early‐life eczema to later‐life internalizing and externalizing problems, rather than the reverse.

What's already known about this topic?

Previous cohort studies using non‐data‐driven methods to define eczema phenotypes observed that children with early‐onset and persistent eczema had a higher risk of emotional and behavioural problems in preadolescence.

Alternatively, previous cohort studies showed that children with emotional and behavioural problems had more severe eczema and eczema exacerbations in childhood.

The direction of effects between eczema and emotional and behavioural problems is not fully clear.

What does this study add?

Taking the variability of eczema onset and persistence within and between children over time into account, all identified eczema phenotypes were very modestly associated with more somatic symptoms and attention problems at school age.

Directional effects seem to occur from eczema leading to emotional and behavioural problems, rather than the reverse.

Future research should focus on the effect of early optimal eczema management on mental health disorders in children later in life.

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Approach to the Assessment and Management of Pediatric Patients with Atopic Dermatitis: A Consensus Document. Section II: Comorbid Disease in Pediatric Atopic Dermatitis

Pediatric atopic dermatitis (AD) is one of the most common skin conditions encountered by health-care providers caring for infants, children, and adolescents. Pediatric patients with AD may present with other allergic and nonallergic comorbidities that require appropriate treatment and referral. They may also experience a trajectory of allergic diseases known as the atopic march, which depends on a complex interaction between genetic and environmental factors and likely involves early epidermal barrier dysfunction. Here we provide a review and clinical recommendations on the assessment and referral of comorbidities in pediatric AD.

Complementary and Integrative Therapies for Childhood Atopic Dermatitis

Background: Childhood atopic dermatitis is a chronic inflammatory skin condition that causes significant psychological and financial costs to the individual and society. Treatment regimens may require long-term medication adherence and can be associated with poor patient satisfaction. There is considerable interest in complementary and integrative medicine (CIM) approaches for childhood atopic dermatitis. Objective: To assess the effects of CIM approaches on childhood atopic dermatitis outcomes as defined by randomized, controlled clinical trials. Methods: A PubMed review of CIM-related treatments for pediatric atopic dermatitis was performed, and data related to age, study population, efficacy, treatment regimen, length of treatment, and sample size were included. Results: The search yielded 20 trials related to probiotic/prebiotic treatments for atopic dermatitis, three on the effects of vitamins on children with atopic dermatitis, and two on the effects of Chinese herbal treatments for atopic dermatitis in children and adolescents. The strongest evidence was for supplementation with the probiotics L. fermentum and L. plantarum. Conclusions: Certain strains of probiotics, specifically L. plantarum and L. fermentum, may improve clinical severity scores in children with atopic dermatitis. However, additional trials are needed to more thoroughly delineate the effects of additional integrative therapies on childhood atopic dermatitis.

Mental health impairment among children with atopic dermatitis: A United States population-based cross-sectional study of the 2013-2017 National Health Interview Survey

BACKGROUND

Atopic dermatitis (AD) is associated with mental health disorders, but its impact on global mental health symptoms is less clear.

OBJECTIVE

To determine the association between pediatric AD and mental health impairment.

METHODS

In a cross-sectional study using 2013-2017 United States National Health Interview Survey data, children with and without AD were assessed for mental disorder with impairment (MDI) using a validated behavioral screening questionnaire. Mental health services utilization was also reported.

RESULTS

The prevalence of any MDI was 26.7% (95% confidence interval [CI], 25.1-28.3) among children with AD and 17.7% (95% CI, 17.2-18.2) among those without AD, with severe MDI being present in 10.9% (95% CI 9.9-12.1) and 6.2% (95% CI 5.9-6.5), respectively. Adjusted for sociodemographic factors, AD was associated with higher odds of MDI (odds ratio, 1.52; 95% CI, 1.39-1.67), including impairments in conduct, emotions, peer relationships, and attention. Among children with AD, 19.9% (95% CI, 16.6-23.8) and 53.5% (95% CI, 48.5-58.5) of those with mild or severe MDI, respectively, had seen a mental health professional in the last year.

LIMITATIONS

Misclassification bias may arise from self-reported data.

CONCLUSION

AD is associated with clinically significant mental health symptoms, but many affected children may not seek or receive care for their symptoms.

New treatments for atopic dermatitis targeting beyond IL-4/IL-13 cytokines

OBJECTIVE

Atopic dermatitis (AD) is an increasingly common inflammatory skin disease undergoing significant revolution in recent years. New data on disease pathogenesis advanced the developments of novel therapeutics, mainly for patients with moderate to severe conditions, for whom treatment options have been largely insufficient for many years.

DATA SOURCES

Review of recent studies investigating systemic treatments for AD.

STUDY SELECTIONS

Relevant literature concerning novel therapeutics for AD beyond targeted monoclonal antibodies antagonizing selectively interleukin (IL)-4 or IL-13 was obtained from a PubMed and clinicaltrials.gov search and summarized.

RESULTS

Multiple clinical trials of both nonspecific as well as specific agents revealed favorable outcomes in AD, including JAK inhibitors, a dual JAK/SYK inhibitor, a histamine H4R antagonist, antagonists of the TSLP/OX40L axis, an IL-22 inhibitor, and IL-33 and IL-17C antagonists. Importantly, negative trials were published as well (eg, phosphodiesterase 4 inhibitor, apremilast).

CONCLUSION

In this rapidly evolving field of AD treatments, a completely new treatment paradigm will be available in the near future.

Risk of Mental Disorders in Children and Adolescents With Atopic Dermatitis: A Systematic Review and Meta-Analysis

Assessing the psychological effects on children and adolescents of suffering atopic dermatitis (AD) is essential, when planning successful management. This study aimed to systematically review the literature regarding risk of mental disorders in children and adolescents with, or without, AD; and to explore confounders. We identified potentially relevant studies from EMBASE, MEDLINE, PsycINFO, ERIC, the British Nursing Index, the Family and Society Studies Worldwide, the Social Work Abstracts, and the Sociological Abstracts from inception to Sep 30, 2018. Investigators independently screened titles and abstracts, and then full-texts. Investigators independently extracted data from included studies. Meta-analyses using random-effects models were performed, reporting odds ratios (ORs; 95% CIs). Thirty-seven studies (n = 2,068,911 children/ adolescents) were included. Meta-analysis of 35 studies found that children and adolescents with AD had significantly higher risk of total mental disorders than those without AD (OR = 1.652; 95% CI, 1.463-1.864). There was no significant difference in risks for ADHD (OR = 1.563; 95% CI, 1.382-1.769); sleep disorders (OR = 2.100; 95% CI, 1.322-3.336); anxiety (OR = 1.339; 95% CI, 1.062-1.687); depression (OR = 1.402 95% CI, 1.256-1.565); conduct disorder (OR = 1.494 95% CI, 1.230-1.815); or ASD (OR = 2.574; 95% CI, 1.469-4.510; Q b = 8.344, p = 0.138). Race/ethnicity of child, target of comparison, type of studies, representativeness of the sample, measures of AD and mental disorders were significant moderators for total mental disorders. Integrated, holistic, multidisciplinary management of pediatric AD is significantly important, which emphasizes the well-being of the whole person.

Depression and psychological distress in US adults with atopic dermatitis

BACKGROUND

Symptoms of anxiety and depression appear to contribute to the overall burden of atopic dermatitis (AD). However, the burden of mental health symptoms and psychological distress in AD have not been fully elucidated.

OBJECTIVE

To determine the prevalence and predictors of depressive symptoms and psychological distress among US adults with AD and how they compare with psoriasis and other disorders.

METHODS

We analyzed the 2004-2015 Medical Expenditure Panel Surveys, a representative sample of US adults. Patient Health Questionnaire-2 (PHQ-2) and Kessler-6 index (K-6) scores assessed depressive symptoms and psychological distress, respectively.

RESULTS

Atopic dermatitis in adults is associated with increased odds of screening positive for depressive symptoms (PHQ-2 ≥2) (44.3% vs 21.9%; adjusted odds ratio [aOR] [95% confidence interval (CI)]: 2.86 [1.14, 7.16]) and severe psychological distress (K-6≥13) (25.9% vs 5.5%; 6.04 [2.28, 15.99]). Adults with vs without AD had increased K6 scores overall (linear regression, P = .04) and severe psychological distress in particular (K-6≥13; logistic regression; adjusted odds ratio [95% CI]: 6.04 [2.28, 15.99]). K-6 scores were associated with lower household income (linear regression; adjusted beta [95% CI]: 6.22 [0.88, 11.56]) and middle income (4.49 [0.39, 8.59]), but inversely associated with black (-7.36 [-11.70, -3.03]) and multiracial/other (-2.85 [-5.67, -0.03]) race/ethnicity.

CONCLUSION

Atopic dermatitis is associated with more depressive symptoms and psychological distress overall, and even worse than many other chronic diseases. These findings highlight the need for clinicians to consider screening for and monitoring mental health symptoms in AD patients. Future studies are needed to develop interventions to reduce psychological distress in AD.

Comorbidities and the impact of atopic dermatitis

OBJECTIVE

Atopic dermatitis (AD) is a chronic pruritic inflammatory skin disease with substantial patient and population burdens. A number of comorbid health problems occur in patients with AD, aside from the cutaneous signs and symptoms. This review summarizes recent developments in the burden and comorbidities of AD.

DATA SOURCES

Literature review.

STUDY SELECTIONS

Nonsystematic.

RESULTS

Different aspects of AD, such as chronic pruritus, psychosocial distress, and inflammation, can lead to anxiety, depression, or suicidality. Atopic dermatitis is associated with and may predispose to higher risk of other atopic disorders, including asthma, hay fever, food allergy, and eosinophilic esophagitis. Persons with AD appear to be at higher risk for infectious and cardiovascular risk.

CONCLUSION

Atopic dermatitis is associated with substantial burden and comorbidities. Identifying AD comorbidities is essential for proper disease management and improving overall patient outcomes.