Disease severity and associated family impact in childhood atopic dermatitis

Impact of Atopic Dermatitis on Quality of Life of Caregivers: A Systematic Review and Meta-Analysis

Abstracts: Background: Atopic dermatitis (AD) is a chronic dermatological condition that affects both patients and their caregivers. Aims: To summarize evidence on the impact of AD on the quality of life (QoL) of caregiver. Methods: Observational studies were searched for in Medline, Embase, Cochrane Library, SCOPUS, and CINAHL databases up till March 1, 2023. Results: Seventy studies with a total of 33,291 study participants were identified. The Dermatitis Family Index (DFI) questionnaire featured in 29 studies and was chosen for further meta-analysis. The pooled DFI for all studies was 9.35 (95% confidence interval [CI] 6.94-11.76). For individual components, the highest component scores were for 1.24 for expenditure (95% CI 0.80-1.69), followed by 1.14 for emotions (95% CI 0.77-1.50), as well as sleep 1.12 (95% CI 0.71-1.54) and exhaustion 1.12 (95% CI 0.76-1.48). Meta-analysis on the effect of patient QoL on family QoL was conducted on 15 studies, with a pooled Spearman's rank coefficient using Infants' Dermatitis Quality of Life Index (IDQoL) was 0.632 (95% CI 0.558-0.707), whereas that using Children's Dermatology Life Quality Index (CDLQI) was 0.624 (95% CI 0.507-0.741). For the 17 studies correlating AD severity with family QoL, a pooled Spearman's rank coefficient of 0.425 (95% CI 0.330-0.521) was obtained. Conclusions: AD is associated with significant negative impacts on caregiver QoL, particularly in family finance, caregiver burnout, and sleep impairment. This was consistently affected by AD severity and patient QoL in all studies examining this association.

Patient education in atopic dermatitis: a scoping review

BACKGROUND

Atopic dermatitis (AD) is a chronic inflammatory skin disease that affects children and adults. Poor treatment adherence in AD requires interventions to promote self-management; patient education in chronic diseases is key to self-management. Many international AD management guidelines published to date include a recommendation for educating patients as part of their treatment but there are no formal recommendations on how to deliver this knowledge. MAIN: We performed a scoping review to map the existing literature on patient education practices in AD and to highlight the clinical need for improved patient education in AD. The literature search was performed with the online databases MEDLINE, Embase, Grey Matters, ClinicalTrails.gov and the International Clinical Trials Registry Platform (ICTRP). The search strategy yielded 388 articles. Of the 388 articles screened, 16 studies met the eligibility criteria, and the quantitative data was summarized by narrative synthesis. The majority of studies were randomized controlled trials conducted in Europe, Asia and North America. Since 2002, there have been limited studies evaluating patient education in the treatment of AD. Frequent education methods used included group-based educational programs, educational pamphlets, individual consultations and online resources. Education was most commonly directed at caregivers and their children. Only one study compared the efficacy of different education methods. In all included studies, the heterogenous nature of outcome measures and study design limited the consistency of results. Despite the heterogeneity of studies, patient education was shown to improve quality of life (QoL), disease severity and psychological outcomes in AD patients.

CONCLUSION

This scoping review highlights that patient education is effective in a variety of domains relevant to AD treatment. Further comparative studies and randomized trials with longer-term follow-up are needed to provide validated and consistent patient education recommendations for AD; these may depend on age and population.

Novel mixed-method, inclusive protocol involving global key stakeholders, including carers as experts, to co-develop relevant Caregiver-Reported Outcome Domains (CRODs) in skin disease

INTRODUCTION

Ichthyoses comprise a heterogenous group of rare genetic skin disorders that involves the entire skin surface, often with additional syndromic features, and pose many clinical challenges. Without curative intervention, the mainstay of life-long symptom management is supportive in nature and can remain the responsibility of the caregiver. Although impact on the wider family is considered an important outcome of policies and services, there is a lack of caregiver consensus on what outcome domains to measure to fully assess the impact of ichthyosis on the patient and the caregiver. This project aims to identify a set of core outcome domains towards a core outcome set for ichthyosis that can measure all relevant concepts of ichthyosis in clinical practice, service delivery and research.

METHODS AND ANALYSIS

Following the COMET (Core Outcome Measures in Effectiveness Trials) initiative, this project will employ a mixed-method study design which was developed using public and patient involvement and an international multidisciplinary expert group (clinical experts, patients and their representatives, policymakers, researchers and service providers). Experts by experience, or caregivers, will be recruited through online ichthyosis support groups. Phase one will focus on item generation and involve: (1) a systematic literature review, (2) a multimethods international qualitative study with ichthyosis caregivers and (3) co-development of items for an e-survey. Phase two, item refinement, will employ a novel four-pronged consensus approach: (1) an e-Delphi survey, (2) statistical analysis of e-Delphi survey results, (3) online qualitative feedback and (4) an online consensus discussion. All methodological considerations will be clearly linked with each Core Outcome Set-STAndards for Developing recommendation.

ETHICS AND DISSEMINATION

Research Ethics Committee approval obtained from the School of Psychology, Ulster University (UK)(Ref:REC/20/0004). Results will be presented in published international peer-reviewed journals, at scientific meetings and support groups.

REGISTRATION

COMET database (January 2019).

Are Environmental Factors for Atopic Eczema in ISAAC Phase Three due to Reverse Causation?

Some previously described environmental associations for atopic eczema may be due to reverse causation. We explored the role of reverse causation by comparing individual- and school-level results for multiple atopic eczema risk factors. The International Study of Asthma and Allergies in Childhood (i.e, ISAAC) Phase Three surveyed children in schools (the sampling unit) regarding atopic eczema symptoms and potential risk factors. We assessed the effect of these risk factors on atopic eczema symptoms using mixed-effect logistic regression models, first with individual-level exposure data and second with school-level exposure prevalence. Overall, 546,348 children from 53 countries were included. At ages 6-7 years, the strongest individual-level associations were with current paracetamol use (odds ratio [OR] = 1.45, 95% confidence interval [CI] = 1.37-1.54), which persisted at school-level (OR = 1.55, 95% CI = 1.10-2.21), early-life antibiotics (OR = 1.41, 95% CI = 1.34-1.48), and early-life paracetamol use (OR = 1.28, 95% CI = 1.21-1.36), with the former persisting at the school level, whereas the latter was no longer observed (OR = 1.35, 95% CI = 1.00-1.82 and OR = 0.94, 95% CI = 0.69-1.28, respectively). At ages 13-14 years, the strongest associations at the individual level were with current paracetamol use (OR = 1.57, 95% CI = 1.51-1.63) and open-fire cooking (OR = 1.46, 95% CI = 1.33-1.62); both were stronger at the school level (OR = 2.57, 95% CI = 1.84-3.59 and OR = 2.38, 95% CI = 1.52-3.73, respectively). Association with exposure to heavy traffic (OR = 1.31, 95% CI = 1.27-1.36) also persisted at the school level (OR = 1.40, 95% CI = 1.07-1.82). Most individual- and school-level effects were consistent, tending to exclude reverse causation.

Corticosteroid phobia (corticophobia) in parents of young children with atopic dermatitis and their health care providers

BACKGROUND

Adherence to topical corticosteroids is low among atopic dermatitis patients and their parents. This can lead to treatment failure and decreased quality of life.

OBJECTIVE

To assess and compare the worries and beliefs concerning topical corticosteroids among parents of children with atopic dermatitis, involved health care professionals, and between different professionals. Also, we identify factors associated with corticosteroid phobia (corticophobia) in professionals.

METHODS

Parents and health care professionals were invited to complete a questionnaire about corticophobia (Topicop). Higher questionnaire scores, expressed as a percentage, indicate more severe corticophobia. Professionals were asked to answer the questions as though they were using topical corticosteroids on their own child.

RESULTS

The scores for 29 parents and 31 public health care nurses were equal: 44%. The score for 51 general practitioners was 39%. The score for 33 public health care physicians and of 47 pediatricians was 31%. The differences between parents and these professionals were statistically significantly different (P = 0.001). Type of profession and having a child with atopic dermatitis were significantly associated factors for the score.

CONCLUSION

Corticophobia is present among parents of children with atopic dermatitis and among health care professionals involved in caring for children with atopic dermatitis. Health care nurses express the same level of corticophobia as parents. The presence of corticophobia among health care professionals may affect parental perspectives and topical corticosteroids adherence negatively.

The impact of pediatric atopic dermatitis on families: A review

BACKGROUND

Atopic dermatitis (AD) is an extremely common childhood disease, with considerable impact on the quality of life of affected children and their families. While pruritus is the hallmark symptom of this disease, AD has been well-documented to impact patients beyond physical symptoms, resulting in behavior problems, mood disorders, and sleep disturbance.

OBJECTIVE

This literature review outlines how atopic dermatitis impacts the quality of life of families of children affected by AD.

METHODS

A total of 3436 articles were identified via an online search of the MEDLINE health literature database and were screened for relevance to quality of life impacts on families with children affected by AD.

RESULTS

Caring for children affected by AD can be an extremely time-consuming task that can impair personal relationships, decrease psychosocial functioning, and cause sleep loss among family members of affected patients. Additionally, AD may result in work absence or decreased work productivity for caregivers. Special diets, irritant and allergen avoidance strategies, and alternative therapies are commonly used by patients to manage their disease and require large amounts of family involvement.

CONCLUSIONS

Atopic dermatitis can greatly decrease quality of life of families of affected children in various domains, including sleep, finances, and relationships. Early intervention and psychotherapy may be needed in some patients to address these quality of life impairments.

Parent-Rated Severity of Illness and Anxiety among Caregivers of Children Born with a Disorder of Sex Development Including Ambiguous Genitalia

BACKGROUND/AIMS

Parents of children born with disorders of sex development (DSD) often experience anxiety, but risk factors, including parental perception of the severity of their child's DSD, have not been examined. We hypothesized that severity of illness (SOI) ratings would relate to parental anxiety, and would be higher for parents of children with a potentially life-threatening DSD (e.g., 21-hydroxylase deficiency).

METHODS

Eighty-nine parents (Mage = 33.0, 56.2% mothers) of 51 children (Mage in months = 8.7) with a DSD including ambiguous genitalia were recruited from 12 specialized DSD clinics. Parents completed questionnaires prior to genitoplasty, 6 months post-genitoplasty, and 12 months post-genitoplasty (if completed). Data were analyzed with linear mixed modeling.

RESULTS

Parental anxiety decreased over time, χ2(1) = 10.14, p < 0.01. A positive relationship between SOI and anxiety was found, with SOI being a strong predictor of anxiety (b = 0.53, p < 0.01; χ2[1] = 5.33, p < 0.05). An SOI by time interaction indicated SOI had an increasing effect on anxiety over time, b = 0.06, p < 0.05; χ2(1) = 6.30, p < 0.05. There was no diagnosis by SOI interaction.

CONCLUSION

Parental anxiety decreased over time, but those with higher SOI ratings reported greater initial anxiety followed by slower resolution over time. Underlying etiology of DSD had no effect on the relationship between SOI and anxiety.

Assessing depression and anxiety in the caregivers of pediatric patients with chronic skin disorders

BACKGROUND

The literature has shown that the presence of emotional disturbances in caregivers of children with skin diseases affects the course and treatment of the disease. Anxiety and depression are among the most frequently reported psychiatric diagnoses related to this fact.

OBJECTIVE

To evaluate the presence of anxiety and depression in caregivers of pediatric patients with chronic skin disorders, exemplified by atopic dermatitis, psoriasis and vitiligo, and correlate them to the quality of life of the patients.

METHODS

The sample consisted of 118 patients with atopic dermatitis, vitiligo and psoriasis, monitored by their main caregiver. The levels of anxiety and depression in the caregivers were assessed using the Hamilton Anxiety Scale and the Beck Depression Inventory, respectively. The Children's Dermatology Life Quality Index was applied.

RESULTS

Anxiety was observed in 36% of the caregivers of the patients with atopic dermatitis, in 36% of those of children affected by psoriasis, and in 42% of those responsible for pediatric patients with vitiligo. Depression occurred in 36% of the caregivers of patients with atopic dermatitis, in 36% of those of children affected by psoriasis and in 26% of those responsible for pediatric patients with vitiligo. There was a significant correlation between poor quality of life scores in patients with vitiligo and the presence of depression and anxiety in their caregivers.

CONCLUSION

Emotional disorders tend to be present among close family members of children with the chronic skin diseases studied and their prevention can help in controlling and treating these diseases.

Parenting and relationship characteristics in mothers with their children having atopic disease

This study compared parental cognitions and relationship characteristics of mothers of children with atopic disease with those of mothers of children without atopic disease. These factors include child-rearing attitudes, parental locus of control, parental sense of competence, attachment security, and maternal sensitivity. Preplanned subanalyses were carried out according to specific disease, mothers' perception of disease severity, and presence of concurrent atopic diseases. The descriptive comparative study of 233 Korean mothers included 102 mothers of children aged six years or younger with atopic dermatitis, asthma, and/or allergic rhinitis. Data were collected from 2007 to 2008 from local clinics and day care centers. Parental cognitions and relationship characteristics did not differ significantly between groups of mothers, except that mothers of children with atopic dermatitis showed less affection. However, subanalyses showed that mothers who perceived their child's disease to be severe were less likely to encourage autonomy and had a lower sense of competence, more rejecting attitudes, and an external locus of control. Although we should be cautious in generalizing these results, special care plans are strongly recommended for mothers of children with severe atopic disease to provide support and education, help mothers develop an internal locus of control, and increase parental sense of competence.

Comparing high altitude treatment with current best care in Dutch children with moderate to severe atopic dermatitis (and asthma): study protocol for a pragmatic randomized controlled trial (DAVOS trial)

Background

About 10 to 20% of children in West European countries have atopic dermatitis (AD), often as part of the atopic syndrome. The full atopic syndrome also consists of allergic asthma, allergic rhinitis and food allergy. Treatment approaches for atopic dermatitis and asthma include intermittent anti-inflammatory therapy with corticosteroids, health education and self-management training. However, symptoms persist in a subgroup of patients. Several observational studies have shown significant improvement in clinical symptoms in children and adults with atopic dermatitis or asthma after treatment at high altitude, but evidence on the efficacy when compared to treatment at sea level is still lacking.

Methods/Design

This study is a pragmatic randomized controlled trial for children with moderate to severe AD within the atopic syndrome. Patients are eligible for enrolment in the study if they are: diagnosed with moderate to severe AD within the atopic syndrome, aged between 8 and 18 years, fluent in the Dutch language, have internet access at home, able to use the digital patient system Digital Eczema Center Utrecht (DECU), willing and able to stay in Davos for a six week treatment period. All data are collected at the Wilhelmina Children’s Hospital and DECU. Patients are randomized over two groups. The first group receives multidisciplinary inpatient treatment during six weeks at the Dutch Asthma Center in Davos, Switzerland. The second group receives multidisciplinary treatment during six weeks at the outpatient clinic of the Wilhelmina Children’s Hospital, Utrecht, the Netherlands. The trial is not conducted as a blind trial. The trial is designed with three components: psychosocial, clinical and translational. Primary outcomes are coping with itch, quality of life and disease activity. Secondary outcomes include asthma control, medication use, parental quality of life, social and emotional wellbeing of the child and translational parameters.

Discussion

The results of this trial will provide evidence for the efficacy of high altitude treatment compared to treatment at sea level for children with moderate to severe AD.

Trial Registration

Current Controlled Trials ISRCTN88136485.

The impact of disease on family members: a critical aspect of medical care

Most existing health-related quality of life research concerns the impact of disease on patients. However, in several medical specialties including dermatology, oncology, and physical and mental disability, studies have been carried out investigating the impact of disease on the lives of families of patients. The aim of this paper is to review the literature which relates to the impact of disease on family members of patients. The OVIDSP Medline was selected as the primary database, Searches were limited to sources published in English. 158 papers were identified for review. The definition of "family" varied across the literature, and a broad definition was accepted in this review. This review shows that a wide variety of aspects of family members' lives can be affected, including emotional, financial, family relationships, education and work, leisure time, and social activities. Many of these themes are linked to one another, with themes including financial impact and social impact being linked to emotional impact. Some positive aspects were also identified from the literature, including family relationships growing stronger. Several instruments exist to measure the impact of illness on the family, and most are disease or specialty- specific. The impact of disease on families of patients is often unrecognised and underestimated. Taking into account the quality of life of families as well as patients can offer the clinician a unique insight into issues such as family relationships and the effect of treatment decisions on the patient's close social group of partner and family.

T cell subsets in cord blood are influenced by maternal allergy and associated with atopic dermatitis

BACKGROUND

This study aimed to investigate the influence of maternal allergy on cord blood regulatory and effector T cells and to evaluate their role as a predictor of atopic dermatitis (AD) during the first 2 yr of life.

METHODS

Seventy mother-infant pairs were recruited in this prospective birth cohort study (21 allergic and 49 non-allergic mothers). Cord blood samples were collected and assayed for the percentage of regulatory T cells (Treg), interferon-γ (IFN-γ), and interleukin-4 (IL-4) producing T cells (Th1 and Th2, respectively) using flow cytometry. Experiments were undertaken to assess the function of cord blood CD4(+) CD25(+) CD127(-) Treg cells by cell proliferation and cytokine responses. Their offspring at the age of 2 yr old were evaluated by dermatologists to determine whether they had AD.

RESULTS

During the first 2 yr of life, 15.7% of the children developed a physician-diagnosed AD. A significantly increased percentage of Th2 cell was observed in cord blood of newborns with maternal allergy. Treg/Th2 ratio significantly decreased among the offspring of allergic mothers. Treg cell-associated suppression of Th2 response was attenuated in Der p1-stimulated CD4(+) CD25(-) T cells from the offspring of allergic mothers. Children with reduced Th1/Th2 (p = 0.001, OR = 0.37) and Treg/Th2 (p = 0.001, OR = 0.47) ratio in cord blood had a higher risk of developing AD.

CONCLUSION

Maternal allergic status is associated with increased percentage of IL-4(+) CD4(+) T cells and a reduced Treg/Th2 ratio in cord blood at their children's birth, which may predispose to an increased risk for developing AD.

Prediction of atopic dermatitis in 2-yr-old children by cord blood IgE, genetic polymorphisms in cytokine genes, and maternal mentality during pregnancy

Atopic dermatitis (AD) is the most common skin disease in childhood and the first step of atopic march. This study aimed to investigate whether AD in children could be better predicted by biologic markers (cord blood IgE [cbIgE], LT-αNcoI alleles, and FcεRI-β E237G genotypes) and maternal mentality during pregnancy, taking into account gender, socio-demographic factors, and parental atopy. From 2001 to 2005, 1264 mother-infant pairs were recruited to participate in a birth cohort study. Prenatal questionnaire was used to collect family history, maternal gestational conditions and mentality, and environmental exposures. Cord blood was collected and assayed for genotypes and IgE levels. Phone interviews at 6 months and 2 yrs of age were conducted to inquire children's health status, including AD occurrence. In addition to the known risk factors such as gender, maternal education, and parental atopy, biomarkers and maternal mentality during pregnancy were screened by logistic regression as candidate predictors of AD. Area-under-curve (AUC) statistic from receiver-operating characteristic (ROC) curve analysis was used to compare two predicting models with and without biomarkers and maternal mentality. A total of 730 pairs completed the prenatal questionnaire and phone interview and were included in final analysis. The prevalence of ever having physician-diagnosed AD by 2-yr-olds was 5.9%. Elevated cbIgE levels (≥0.5 kU/l), LT-αNcoI alleles, FcεRI-β E237G genotype, and maternal psychologic stress during pregnancy were significantly associated with AD. Comparison with AUCs of the classic model (including gender, maternal education, and parental atopy), the model adding cbIgE levels, genotypes in cytokine genes, and maternal stress (model 2) showed higher ability to discriminate between children with and without AD (AUC statistics: 0.63 [95% CI = 0.60-0.67] vs. 0.73 [95% CI = 0.70-0.76], respectively; model comparison, p = 0.027). We conclude that elevated cbIgE, LT-α and FcεRI-β genotypes, and maternal stress during pregnancy were associated with ever having physician-diagnosed AD in 2-yr-old children and increased the predictive ability for AD after taking into account gender, maternal education, and parental atopic history.

Quality of life in infants with atopic dermatitis and healthy infants: a follow-up from birth to 24 months

AIM

To evaluate quality of life (QOL) in infants with atopic dermatitis (AD) by comparison with healthy infants to find treatment modalities contributing most to QOL in these patients.

METHODS

The population (N=134) was recruited in the context of an on-going prospective mother-infant study. QOL was measured using the Infant Dermatitis Quality of Life Index for the infants with AD and a modification of this for the healthy infants.

RESULTS

The index scores of infants with AD were 4.15 (SD 2.96), 3.89 (SD 3.62) and 3.23 (SD 2.71) at 6, 12 and 24 months, respectively, the QOL being significantly poorer at 6 (p<0.001) and 12 (p=0.01) months compared to healthy infants. The principal impairments were itching, scratching and sleep disturbances at 6 and 12 months and treatment difficulties at 6 months. Problems with getting to sleep were reported at all stages irrespective of AD.

CONCLUSIONS

Simple treatment regimens targeting itching in particular are likely to contribute most to the QOL of infants with AD; however, sleeping problems may remain as an age-related phenomenon. Early detection of symptoms and effective parent guidance contributed to the well-being of the child.

The impact of childhood atopic dermatitis on the patients' family

Atopic dermatitis is a common childhood disease that impairs quality of life. The study aimed to clarify the impact of childhood atopic dermatitis on family life and to correlate severity of atopic dermatitis with family life. A cross-sectional survey was conducted at Qassim Region of Saudi Arabia over a period of 4 months extending from April to July 2009. The parents of children with atopic dermatitis were asked through a validated "Dermatitis Family Impact Questionnaire" about the impact of the disease on their life. For each questionnaire, a total score of 0 to 5 is considered as normal quality of life, 6 to 10 as low, 11 to 20 as moderate and >20 as high alteration in quality of life. The severity of the disease was evaluated using the SCORAD index. A total of 447 children with atopic dermatitis were included in the study. Their mean age was 65.9 months. Males constituted 57% of the patients. The mean score for quality of life in affected families was 13.9 (minimum 2, maximum 25). Based on our suggested classification, only 15 (3.4%) had normal quality of life, 104 (23.3%) were mildly affected, 297 (66.4%) were moderately affected, while 31 (6.9%) reported severe alternation in their quality of life. Sleep, monthly expenditure, and food preparation were the activities showing the highest level of disturbance. The disturbance in quality of life was significantly correlated to increasing severity of the disease. The study has emphasized the importance of investigating the quality of life of atopic dermatitis families. A simple questionnaire is a useful guide for appropriate management of the disease.

Quality-of-life outcomes and measurement in childhood atopic dermatitis

Atopic dermatitis is a common childhood skin disease of increasing prevalence that greatly affects the quality-of-life of affected children and their families. The complex and multidimensional effects of this disease have been described qualitatively and measured quantitatively with quality-of-life instruments. The burden of atopic dermatitis can likely be improved by identifying parents and their caregivers with impaired quality-of-life and providing appropriate education and psychosocial support.

The influence of childhood atopic dermatitis on health of mothers, and its impact on Asian families

This study examines maternal perceptions of paediatric atopic dermatitis (AD) on family and determines risk factors including severity of AD, maternal physical and mental health (MH), quality of life of patients and sociodemographics which predict a negative family impact. A cross-sectional assessment using the Dermatitis Family Impact Questionnaire Scale to assess the impact of AD on family, Infant's Dermatitis Quality of Life Index (<5-yrs old) or Children's Dermatitis Life Quality Index (5-17 yrs old) was used to measure health-related quality of life (HRQOL) of paediatric patients with AD. A 12-item Short-Form Health Survey (SF-12) was used to assess physical and MH of their mothers. Risk factors of adverse family impact were assessed using multiple regression analysis. One hundred and four patients with AD and their mothers were studied. Their mean ages (+/-s.d.) were respectively 6.4 +/- 4.3 and 37.2 +/- 6.6 yrs. In multiple regression analysis, Severity Scoring of Atopic Dermatitis (SCORAD) appeared to be associated with negative family impact and the association remained significant after adjustment for bio-psycho-social factors and HRQOL of patients. The association remained insignificant after adjustment for physical and MH of the mothers. Our results show that the severity of paediatric AD leads to negative family impact through reduction of physical and MH of the mothers, and is independent of patients' HRQOL and sociodemographics. The current approach for managing paediatric AD in Asian society could include early multidisciplinary intervention, aiming at enhancing physical and MH of mothers while minimizing negative impact on family and social isolation. Further research will be welcomed as the results of this study mainly applied to Asian society which could be different to populations from other geographic areas.

Interferon treatment for chronic hepatitis C: a family impact study

Hepatitis C virus is estimated to affect 170 million people worldwide. Infection can lead to cirrhosis, liver failure, or liver cancer. Hepatitis C is unique among chronic illnesses, in that potentially curative treatment is available. Therapy is of prolonged duration and associated with multiple physiological and psychological side effects. These side effects have the potential to impact not only the individual receiving therapy but also their family and the day-to-day functioning of the family unit.This paper describes data and findings obtained from a family impact study instigated to explore the repercussions of interferon treatment for chronic hepatitis C on family life, from both the perspectives of individuals who had received treatment and their family members. An exploratory study was conducted using semi-structured focus groups.Findings reveal the treatment impacted on physical, emotional, relational, and financial domains. The major themes identified were resilience, loss, hardship, anger and irritability, and secrecy. The side-effect profile of therapy exerted significant and previously unforeseen impacts on family relationships, both negatively and positively. Treatment receivers tended to view their experiences as having more adverse impact, while family members, although affected, demonstrated considerable resilience and coping.

Predicting risk for early infantile atopic dermatitis by hereditary and environmental factors

BACKGROUND

Hereditary and environmental factors contribute to the occurrence of atopic dermatitis (AD). However, the interaction of these two factors is not totally understood.

OBJECTIVES

To evaluate the early risk factors for infantile AD at the age of 6 months and to develop a predictive model for the development of AD.

METHODS

In 2005, a representative sample of mother and newborn pairs was obtained by multistage, stratified systematic sampling from the Taiwan national birth register. Information on hereditary and environmental risk factors was collected by home interview when babies were 6 months old. Multivariate regression analysis was applied to determine the risk factors for AD in the infants.

RESULTS

A total of 20 687 pairs completed the study satisfactorily. AD was diagnosed in 7.0% of 6-month-old infants by physicians. Parental asthma, atopic dermatitis and allergic rhinitis, and maternal education levels were risk factors for AD in infants. Among environmental factors, fungus on walls at home and renovation/painting in the house during pregnancy were significantly associated with early infantile AD. Using these factors, the probability of having infantile AD was estimated and grouped into low, high and very high. With five runs of tests in mutually exclusive subsets of this population, the likelihood of AD for 6-month-old infants was consistent in all the groups with the predictive model. The highest predicted probability of AD was 70.1%, among boys with maternal education levels > 12 years, both parents with AD, renovation and painting of the house during pregnancy and fungus on walls at home. The lowest probability was 3.1%, among girls with none of the above factors.

CONCLUSIONS

This investigation provides a technique for predicting the risk of infantile AD based on hereditary and environmental factors, which could be used for developing a preventive strategy against AD, especially among those children with a family history of atopy.

The impact of rotavirus gastroenteritis on the family

BACKGROUND

Rotavirus is the leading cause of severe diarrhea in young children and causes substantial morbidity and mortality. Although the clinical aspects have been well described, little information is available regarding the emotional, social, and economic impact of rotavirus gastroenteritis on the family of a sick child. The objectives of this study were to: 1) assess the family impact of rotavirus gastroenteritis through qualitative interviews with parents; 2) compare the clinical severity of rotavirus-positive and negative gastroenteritis; 3) test a questionnaire asking parents to rank the importance of various factors associated with a case of rotavirus gastroenteritis.

METHODS

The study enrolled parents and children (2-36 months of age) brought to one of the study sites (outpatient clinic or ER) if the child experienced > or = 3 watery or looser-than normal stools and/or forceful vomiting within any 24-hour period within the prior 3 days. The clinical severity of each child's illness was rated using a clinical scoring system and stool samples were tested for rotavirus antigen. Parents of rotavirus-positive children were invited to participate in focus group or individual interviews and subsequently completed a questionnaire regarding the impact of their child's illness.

RESULTS

Of 62 enrolled children, 43 stool samples were collected and 63% tested positive for rotavirus. Illness was more severe in children with rotavirus-positive compared to rotavirus-negative gastroenteritis (92% vs. 37.5% rated as moderate/severe). Seventeen parents of rotavirus-positive children participated in the interviews and completed the written questionnaire. Parents were frightened by the severity of vomiting and diarrhea associated with rotavirus gastroenteritis, and noted that family life was impacted in several ways including loss of sleep, missed work, and an inability to complete normal household tasks. They expressed frustration at the lack of a specific medication and the difficulty of treating the illness with oral rehydration solutions, but had a largely positive outlook concerning the prospect of a rotavirus vaccine.

CONCLUSION

A better understanding of how rotavirus gastroenteritis impacts the family can help healthcare providers ease parental fears and advise them on the characteristics of this illness, practices to prevent infection, and the optimal care of an affected child.

What are the best outcome measurements for atopic eczema? A systematic review

BACKGROUND

Valid and reliable outcome measurements are a prerequisite for evidence-based practice. The comparative validity and reliability of outcome measurements for assessing atopic eczema (AE) severity is unclear.

OBJECTIVE

We sought to assess the validity, reliability, sensitivity to change, and ease of use of outcome measurements for AE. We also sought to give recommendations on which outcomes to use in clinical research and for clinical monitoring.

METHODS

We performed a systematic review and survey of clinical experts and patients.

RESULTS

Twenty published outcome measurements were identified. There is evidence of adequate construct validity for 3 measurements (Severity Scoring of Atopic Dermatitis index [SCORAD], Eczema Area and Severity Index [EASI], and Three Item Severity Score), adequate internal consistency of 1 scale (Patient-oriented Eczema Measure [POEM]), adequate interobserver reliability of 5 measurements (Basic Clinical Scoring System; Nottingham Eczema Severity Score; Objective Severity Assessment of Atopic Dermatitis; Six Area, Six Sign Atopic Dermatitis severity score; and SCORAD), adequate test-retest reliability of 1 scale (POEM), and adequate sensitivity to change of 3 measurements (EASI, SCORAD, and Investigators' Global Atopic Dermatitis Assessment). Most outcome measurements have adequate content validity, as assessed by patients and experts. Data on the time to perform the assessment was identified for 8 outcome measurements. Only SCORAD, EASI, and POEM have been tested sufficiently and performed adequately.

CONCLUSION

There are too many published outcome measures for AE. Most have not been tested properly or perform adequately when tested, and their continued use hampers scientific communication.

CLINICAL IMPLICATIONS

Only SCORAD, EASI, and POEM currently perform adequately. These scales should be used in future studies.

Stress in mothers of young children with eczema

OBJECTIVE

To assess parental stress levels of mothers of children less than 6 years old with eczema and compare these levels with those reported for other chronic childhood illnesses.

METHODS

Mothers were recruited from hospital-based out-patient clinics (55%) or while their child was an in-patient (45%) for management of eczema. Maternal stress was measured utilising the Parenting Stress Index-Long Form (PSI) in 33 mothers. The severity of the eczema at the time of interview was documented by the Eczema Area and Severity Index (EASI) score and the Investigators' Global Assessment (IGA) score.

RESULTS

The children with eczema had a mean age of 2.8 years. Mothers of children aged 5 years or less with eczema exhibited significantly higher total stress scores (mean PSI 259.6, 95% CI 244.9 to 274.3) as compared to mothers of normal children (PSI 222.8, 95% CI 221.4 to 224.2) and children with other chronic disorders such as insulin-dependent diabetes (PSI 218.1, 95% CI 204.7 to 231.6) and profound deafness (PSI 221.7, 95% CI 206.4 to 237.0). Stress scores in the parental domain (138.2, 95% CI 128.9 to 147.6) did not differ significantly from the scores of parents of children with severe disabilities such as those requiring home enteral feeding (135.2, 95% CI 129.3 to 141.1) and those with Rett syndrome (132.8, 95% CI 125.0 to 140.6).

CONCLUSIONS

Moderate to severe childhood eczema should be regarded as a significant illness in which maternal stress is equivalent to that associated with the care of children with severe developmental and physical problems.

The Family Dermatology Life Quality Index: measuring the secondary impact of skin disease

BACKGROUND

Skin diseases are known to have a major impact on the lives of patients and their families. Many instruments are available to measure the health-related quality of life (HRQoL) of patients but no measure has been developed so far to quantify the secondary impact on family members of the patients.

OBJECTIVES

To develop and validate a dermatology-specific instrument to measure the adverse impact on the HRQoL of family members of patients with skin disease.

METHODS

Detailed semi-structured interviews were conducted with family members of patients to identify different aspects of HRQoL affected. An initial draft version of the questionnaire based on the main topic areas was pilot tested to assess the face and content validity. A 10-item questionnaire, the Family Dermatology Life Quality Index (FDLQI), was finalized after modifications to the draft questionnaire based on feedback from families and dermatology professionals and on item reduction. Psychometric evaluation was conducted on a new cohort of family members (n = 132) who completed the FDLQI and the patients (n = 109) who completed the Dermatology Life Quality Index (DLQI).

RESULTS

Fifty-nine different aspects of family members' HRQoL were identified from the analysis of the interviews, which were categorized into main topic areas. Factor analysis of 10 items of the final questionnaire revealed two factors and together these explained 60% of the common variance. The FDLQI demonstrated high internal consistency (Cronbach's alpha = 0.88) and test-retest (intraclass correlation coefficient = 0.94) reliabilities. The responsiveness of the instrument to change was shown by significant change in the family members' FDLQI scores in cases where patients' clinical condition either improved or worsened. Construct validity was assessed by testing a number of a priori hypotheses. A strong correlation was seen between the family members' FDLQI scores and patients' DLQI scores (r = 0.69), a significantly higher FDLQI score was seen for inflammatory skin diseases compared with noninflammatory diseases/isolated lesions (P < 0.0001), and there was a positive relationship between the family members' FDLQI scores and patients' disease severity (r = 0.49).

CONCLUSIONS

The FDLQI is simple and practical and seems to have the potential to be used as an additional outcome measure in clinical practice and evaluation research.

The psychosocial burden of childhood atopic dermatitis

Atopic dermatitis is an extremely common childhood disease of increasing prevalence that greatly affects the quality of life of afflicted children and of their families. The disease alters the emotional and social functioning of the affected child and their family. The complex multidimensional effects of atopic dermatitis in children and families have been described qualitatively and measured quantitatively with quality of life instruments. Emotional effects on both the child and parents are predominant. The burden of atopic dermatitis can be improved by targeting parents and caregivers with education, psychosocial support, and specialty care.

Life quality assessment among patients with atopic eczema

BACKGROUND

Quantification of quality of life (QoL) related to disease severity is important in patients with atopic eczema (AE), because the assessment provides additional information to the traditional objective clinical scoring systems.

OBJECTIVES

To measure health-related QoL (HRQoL) in patients with AE; to analyse discriminant, divergent and convergent validity by examining the association between various QoL methods; and to examine the association between disease severity assessed by an objective Severity Scoring of Atopic Dermatitis (SCORAD) and QoL.

METHODS

HRQoL was assessed at two visits at a 6-monthly interval in 101 patients with AE and 30 controls with one dermatology-specific questionnaire [Dermatology Life Quality Index (DLQI) or Children's DLQI (CDLQI)], one generic instrument (SF-36) and three visual analogue scales (VASs) of severity and pruritus. Objective SCORAD was used to measure disease severity.

RESULTS

Patients with AE had significantly lower QoL than healthy controls and the general population. DLQI /CDLQI, pruritus, and patient and investigator overall assessment of eczema severity were significantly (P < 0.0001) and positively correlated with SCORAD, while the generic questionnaire showed only poor correlation. A gender difference was found for the mental component score of SF-36 (P = 0.019).

CONCLUSIONS

AE has an impact on HRQoL. Patients' mental health, social functioning and role emotional functioning seem to be more affected than physical functioning. A simple VAS score of patients' assessment of disease severity showed the highest and most significant correlations with most of the HRQoL methods used. There is evidence to support the ability of patients with AE to make an accurate determination of their disease severity and QoL.

Atopic dermatitis: beyond the itch that rashes

The prevalence of atopic dermatitis is increasing, and more than 50% of children with atopic dermatitis go on to develop asthma and allergies. A better understanding of the underlying immune abnormalities of this complex chronic relapsing skin disease is needed. Although the optimal treatment approach remains to be defined, several recent studies suggest a rationale for using topical calcineurin inhibitors as early intervention and adding topical corticosteroids as rescue therapy if needed.

The burden of atopic dermatitis: impact on the patient, family, and society

Atopic dermatitis is a common disease of increasing prevalence. Affected individuals must cope with a significant psychosocial burden, in addition to dealing with the medical aspects of the disease. Furthermore, because this is primarily a disease of childhood, family members, especially parents, are also affected by the condition. Individuals and family members are burdened with time-consuming treatment regimens for the disease, as well as dietary and household changes. The financial impact of atopic dermatitis on families can also be great. Moreover, the cost to society is significant, with estimates ranging from less than 100 dollars to more than 2000 dollars per patient per year. It is estimated that the direct cost of atopic dermatitis in the United States alone is almost 1 billion dollars per year. Reducing the onus of this disease must take into account the full breadth of its burden. Targeting parents and caregivers with education and psychosocial support can decrease family and personal burden, which in turn may decrease the cost of treating the condition because of better medical, psychosocial, and family outcomes.

Atopic dermatitis update

PURPOSE OF REVIEW

Atopic dermatitis, one of the most common chronic illnesses of childhood, is encountered routinely by all providers of health care to children.

RECENT FINDINGS

In recent years there has been a dramatic rise in the prevalence of atopic dermatitis and therefore a rapid increase in the number of studies investigating various aspects of the disease. Consequently, hundreds of publications are released each year, and it is difficult to stay up to date on the latest advances.

SUMMARY

This review will examine and summarize recent literature on the diagnosis, epidemiology, pathogenesis, treatment, and complications of atopic dermatitis.