Atopic Dermatitis Severity, Patient Perception of the Disease, and Personality Characteristics: How Are They Related to Quality of Life?

Atopic Dermatitis-Related Problems in Daily Life, Goals of Therapy and Deciding Factors for Systemic Therapy: A Review

Background/Objectives/Methods: Atopic dermatitis (AD) impacts various aspects of patients' lives including personal life, psychological aspects/disturbances (e.g., depression, anxiety, or even suicidal thoughts), school, and work-related activities, including career advancement. The aim of this narrative review is to present the latest information available on how to best approach AD patient management, as well as decisions regarding standard/advanced systemic therapy, by gathering evidence from the relevant medical literature (PubMed and other prominent medical databases). Results: Thus, AD patient management and decisions regarding advanced/systemic therapy are complex, requiring the consideration of multiple disease-related factors: age; disease severity; patient medical history and comorbidities; previous topical therapy use and any adverse reactions; treatment efficacy concerns; patient preferences, expectations and fears; pregnancy planning; ability and willingness to adhere to the treatment regimen; impact on related risks; and any associated psychological or psychiatric issues. Current guidelines and systematic reviews support the safety and efficacy of systemic therapy including conventional drugs (cyclosporine, methotrexate, and azathioprine), biologics (dupilumab and tralokinumab), and JAK inhibitors (baricitinib, upadacitinib, and abrocitinib) recommended for treating moderate and severe AD. Recently, additional biologics have been evaluated in clinical trials, including lebrikizumab, nemolizumab, eblasakimab, and OX40/OX40L, among others. Conclusions: The most recently suggested approach to treating AD patients suggests focusing on therapy that targets and achieves minimal disease activity (MDA), where therapy decisions are informed by both the patient and the clinician. Available data also indicate the importance of a personalized, stepwise, and multidisciplinary approach. This type of approach promotes patient compliance, satisfaction with therapy, and increased engagement, which all lead to better patient outcomes.

Exploring the interplay of atopic dermatitis severity with sleep and mental health: a case-control study in adult patients

OBJECTIVES

Atopic dermatitis (AD) is a chronic inflammatory skin disease often associated with non-atopic comorbidities. Recently, a severity-dependent relationship between AD and sleep/mental health diseases has been proposed. However, few studies investigated these comorbidities and their association with AD severity through validated questionnaires. This study aimed to use a set of validated instruments to assess the impact of AD on sleep and psychological disorders and estimate the association of itch and AD severity with sleep disorders and psychological symptoms, distinguishing between clinical-oriented and patient-oriented measures.

METHODS

We conducted a case-control study, recruiting 57 adult AD patients (mean age ± std. dev. 34.28 years ± 13.07; 27 males) matched for age and sex with 57 healthy adults (34.39 years ± 13.09; 27 males). To investigate the differences in sleep quality, insomnia, depression, and anxiety between the two groups, we performed independent sample t-Tests. Moreover, we conducted univariate linear regression analyses to examine the relationship between itch and objective/subjective severity of AD and sleep quality, insomnia, and psychological symptoms.

RESULTS

AD patients reported lower sleep quality (p = 0.002), more severe insomnia (p = 0.006) and depression (p = 0.013), and higher stress levels than healthy adults (p = 0.049). Itch intensity was linked to sleep disturbances and psychological symptoms (R2range = 0.13-0.19, prange = 0.02-<0.001). Objective and subjective AD severity were similarly associated with worse sleep quality (R2 = 0.26, p < 0.001; R2 = 0.24, p < 0.001; respectively), anxiety (R2 = 0.15, p = 0.04; R2 = 0.17, p = 0.001; respectively), and self-perceived stress (R2 = 0.10, p = 0.02; R2 = 0.07, p = 0.049; respectively). However, subjective AD severity was more strongly associated with insomnia (R2 = 0.31, p < 0.001) and depression (R2 = 0.20, p < 0.001) than clinical-oriented AD severity (R2 = 0.19, p < 0.001; R2 = 0.05, p = 0.098; respectively).

CONCLUSIONS

The study demonstrated poor sleep quality and high levels of insomnia, depression, and stress in AD patients, with an aggravated psychological status for adults with more severe skin disease. We suggest implementing a multidisciplinary approach to AD management/treatment that considers objective and subjective measures of disease severity.

Atopic Dermatitis: Disease Features, Therapeutic Options, and a Multidisciplinary Approach

The latest findings regarding AD pathogenesis point to an impaired function of the epidermal barrier, changed immune response, colonization of the skin by microorganisms, and certain psychological factors among other causes/triggers. The inflammatory response of AD patients is mainly associated with the activation of T cells (Th2 cells predominate), dendritic cells, macrophages, keratinocytes, mast cells, and eosinophils. Therapy usually involves medical evaluations and adequate management including treatment of concomitant diseases (e.g., allergies and infections), patient education and nursing care, psychological support, and nutritional consultations, which are organized through specific programs and structured educational groups. Systemic AD therapy includes conventional systemic treatment (cyclosporine, methotrexate, azathioprine) and new, specific drugs, interleukin inhibitors (e.g., dupilumab) and JAK inhibitors (baricitinib, abrocitinib, upadacitinib, etc.). Since many AD patients are affected by various psychological factors and comorbidities, they should be assessed and managed through a multidisciplinary approach, involving different professions (psychologists, ear-nose-throat specialists, pulmonologists, allergologists, immunologists, nutritionists, pediatricians, gastroenterologists, psychiatrists (when necessary), and others). A multidisciplinary approach provides better coping strategies and improves control over the disease, patient adherence to therapy, and quality of life. It also has a positive influence on family quality of life while at the same time making more efficient use of dermatology healthcare resources, reducing the economic burden on both patients and society.

Psychological Stress and Hand Eczema in Physicians and Dentists: A Comparison Based on Surgical Work

BACKGROUND

This research looks at the connection between psychological stress and the prevalence of hand eczema (HE) among physicians and dentists (surgeons, non-surgeons).

METHODS

This cross-sectional field study involved 185 participants: physicians (surgeons, non-surgeons), dentists (surgeons, non-surgeons) and controls. Hand lesions were examined using the Osnabrueck Hand Eczema Severity Index (OHSI), and participants answered the Nordic Occupational Skin Questionnaire (NOSQ) and Perceived Stress Scale (PSS). Patch tests were performed using commercial contact allergens.

RESULTS

The estimated prevalence of HE (self-reported) was 43.9% (physicians 44.6%; dentists 43.2%). HE was significantly more reported by surgeons than controls (p < 0.004; V = 0.288). Degrees of perceived stress (PSS) did not differ significantly between the groups, though physicians non-surgeons most exhibited high stress (50%), and physicians surgeons most exhibited low stress (22.5%). High stress was associated with 2.5 higher odds for self-reported HE (p = 0.008). Low stress was greater among physicians/dentists who did not report eczema (41.0% vs. 24.6%); moderate stress was more common among those who reported eczema (72.3% vs. 51.8%; p = 0.038; V = 0.210).

CONCLUSIONS

Since high stress levels may negatively influence physicians'/dentists' work and quality of life, measures to decrease stress could be introduced into the treatment of healthcare workers who are prone to it.

Factors Participating in the Occurrence of Inflammation of the Lips (Cheilitis) and Perioral Skin

Lip inflammation may manifest as mainly reversible cheilitis, mainly irreversible, or cheilitis connected to dermatoses or systemic diseases. Therefore, knowing a patient’s medical history is important, especially whether their lip lesions are temporary, recurrent, or persistent. Sometimes temporary contributing factors, such as climate and weather conditions, can be identified and avoided—exposure to extreme weather conditions (e.g., dry, hot, or windy climates) may cause or trigger lip inflammation. Emotional and psychological stress are also mentioned in the etiology of some lip inflammations (e.g., exfoliative cheilitis) and may be associated with nervous habits such as lip licking. To better manage cheilitis, it is also helpful to look for potential concomitant comorbidities and the presence of related diseases/conditions. Some forms of cheilitis accompany dermatologic or systemic diseases (lichen, pemphigus or pemphigoid, erythema multiforme, lupus, angioedema, xerostomia, etc.) that should be uncovered. Occasionally, lip lesions are persistent and involve histological changes: actinic cheilitis, granulomatous cheilitis, glandular cheilitis, and plasmacellular cheilitis. Perioral skin inflammation with simultaneous perioral dermatitis can have various causes: the use of corticosteroids and cosmetics, dysfunction of the skin’s epidermal barrier, a contact reaction to allergens or irritants (e.g., toothpaste, dental fillings), microorganisms (e.g., Demodex spp., Candida albicans, fusiform bacteria), hormonal changes, or an atopic predisposition. Epidermal barrier dysfunction can worsen perioral dermatitis lesions and can also be related to secondary vitamin or mineral deficiencies (e.g., zinc deficiency), occlusive emollient use, sunscreen use, or excessive exposure to environmental factors such as heat, wind, and ultraviolet light. Current trends in research are uncovering valuable information concerning the skin microbiome and disruption of the epidermal barrier of persons suffering from perioral dermatitis. Ultimately, an effective approach to patient management must take all these factors and new research into account.

Somatization in dermatology

Medically unexplained dermatologic symptoms, such as pruritus, numbness and burning are known as somatization. These cutaneous symptoms can be very difficult to treat because of an absence of an objective explanation and they may not fit neatly into any known dermatological or psychiatric condition. These disorders are more commonly encountered in primary care and in dermatology, rather than in psychiatry. Certain skin disorders, for example, pruritus, could be a manifestation of somatization and others may predispose to somatic symptoms, for example, atopic dermatitis and psoriasis. Although there has been increasing research in the interconnection between psychiatry and dermatology, psychodermatology is a relatively new crossover discipline in clinical practice and recognition of psychodermatological conditions, such as cutaneous somatic disorders, can be difficult. Somatization may occur with or without the existence of a dermatological disease. When a dermatological disorder is present, somatization should be considered when the patient is worrying too much about their skin, spending too much time and energy on it and especially if the patient also complains of many non-cutaneous symptoms. Purely cutaneous somatic conditions include for example, the genital pain syndromes or Gardner-Diamond syndrome, characterized by unexplained bruising, which usually affects women. Effective management tools may include mindfulness therapies, pharmacotherapy with selective serotonin reuptake inhibitors, tricyclic antidepressants and cognitive conduct therapy. Electroconvulsive therapy can also be considered in extremely rare cases for treatment of severe somatization on a background of mood disorders. This paper discusses somatization, its relationship to immunodermatoses and its relevance to clinical practice.