Burden of childhood atopic dermatitis

Sleep disturbance is a significant problem for infants and has been associated with a range of daytime behavioural deficits (Hart et al., 2005; Hiscock et al., 2007; Gregory et al., 2008; Yokomaku et al., 2008). Over 60% of children with atopic dermatitis experience disturbed sleep patterns with rates of up to 89% in children during exacerbations (Reid & Lewis-Jones, 1995; Hanifin et al., 2007; Wittkowski et al., 2007). Furthermore, a U.S. population-based study found that children with atopic dermatitis had sleep disturbance at least 4 nights a week (Silverberg & Simpson, 2013).

Behavioural problems

Characterised by poor initiation, frequent awakenings and prolonged nocturnal wakefulness, disturbance to sleep in children with atopic dermatitis may result in more than the expected daytime fatigue (Camfferman et al., 2010; Drucker, 2017). Sleep disturbance has been linked to daytime behavioural problems including reduced child and family quality of life, increased discipline problems and attention deficit hyperactivity disorder (ADHD) (Camfferman et al., 2010).

Percentage of children with atopic dermatitis above the clinical cut-off for selected sleep and behavioural issues.

Figure 9: Percentage of children above the clinical cut-off for selected sleep and behavioural issues (Camfferman et al., 2010).

Subsequent confirmatory factor analyses indicated that asthma, atopic dermatitis and allergic rhinitis have a significant effect on childhood behaviour with it being substantially, but not completely, mediated by their impact on sleep (Camfferman et al., 2010). Population-based studies have sought to confirm the association between atopic dermatitis, sleep and ADHD. In a German cross-sectional study, a significant association was observed between atopic dermatitis and ADHD (OR 1.54, p<0.001) with a stronger association seen in those with sleep problems (OR 2.67, p=0.001) (Romanos et al., 2010). More recently, analysis of cross-sectional data from 19 U.S.-based population surveys identified a pooled prevalence of atopic dermatitis of 10.1% among the 354,416 children included. A multivariate model that adjusted for a range of factors identified an association between atopic dermatitis and attention deficit disorder (ADD)/ADHD (Odds ratio 1.14; 95% CI 1.03–1.26). However, other risk factors were also identified that increased the risk of ADD/ADHD including disease severity and sleep disruption (Strom et al., 2016).

Table 2: Association between atopic dermatitis severity, sleep and ADHD in the U.S. National Survey of Children’s Health 2007–2008 (Strom et al., 2016).

Association between atopic dermatitis severity, sleep and ADHD in the U.S. National Survey of Children’s Health 2007–2008 (Strom et al., 2016)

However, whether the presence of atopic dermatitis in pre-school children leads to increased levels of medication for ADHD remains uncertain. A Swedish birth cohort of 3,606 children found no association between pre-school (1–4 years of age) atopic dermatitis and prescription of ADHD treatments during school age (10–18 years of age) with a crude odds ratio of 1.16 (95% CI 0.83–1.61) (Johansson et al., 2017).

Mental health burden

For a number of years, an association has been established between atopic dermatitis and mental health issues with twice the rate of psychological disturbance in school-aged children with the condition versus controls (Absolon et al., 1997). Infants with atopic dermatitis have also been shown to be excessively clingy (50% vs. 10% in controls) and fearful (40% vs. 10% in controls) (Daud et al., 1993). Recently, more well-defined mental health disorders have also been associated with atopic dermatitis including depression, anxiety, and autism. A cross-sectional analysis of the 2007 U.S. National Survey of Children’s Health found atopic dermatitis to be a significant risk factor for depression (OR 1.81; 95% CI 1.33–2.46), anxiety (OR 1.77; 95% CI 1.36–2.29), conduct disorder (OR 1.87; 95% CI 1.46–2.39) and autism (OR 3.04; 95% CI 2.13–4.34). The association also strengthened with increasing atopic dermatitis severity (Yaghmaie et al., 2013).

The impact of atopic dermatitis on mental health continues into adolescence. A cross-sectional, questionnaire-based study of 3,775 adolescents (18–19 years) observed that those with atopic dermatitis were more likely to report mental health problems (OR 1.72; 95% CI 1.21–2.45), mental distress (OR 1.63; 95% CI 1.23–2.16) and, worryingly, suicidal ideation (15.5% vs. 9.1%; OR 1.87; 95% CI 1.31–2.68) compared to those without. In a subgroup analysis, those who had atopic dermatitis and itchy skin in the past week were significantly more likely to have these issues, with the odds ratio for suicidal ideation increasing substantially (OR 3.57; 95% CI 2.46–5.67) (Halvorsen et al., 2014).

Impact on physical and social activities

A survey of children in tertiary care for atopic dermatitis highlighted several physical and social functions that are impacted by the condition (Chamlin et al., 2004).

Physical and social functions impacted by atopic dermatitis in children.

Figure 10: Physical and social functions impacted by atopic dermatitis in children (Chamlin et al., 2014).

While the setting of this survey means the data is focussed on patients with more severe disease, subsequent studies have identified itching/scratching, impacts on sleep, treatment, sports and embarrassment related to the condition as those that most affect quality of life (Drucker et al., 2017a). Embarrassment is a significant issue in patients with atopic dermatitis. In a survey of 429 patients, 45%, 54% and 77% of patients with mild, moderate and severe atopic dermatitis, respectively, reported feeling embarrassed or self-conscious in public sometimes, often or almost always. Levels of embarrassment are also linked to age with 90% of patients aged 8 to 15 years feeling embarrassed at least sometimes because of their condition (Paller et al., 2002).

Restrictions placed on children with atopic dermatitis to help prevent and control their condition can have further implications, affecting children’s confidence, independence, and self-esteem. Such limitations, in addition to the chronic symptoms of atopic dermatitis, can also affect how they interact with their peers and how they perform at school (Ward, 2004; Lee et al., 2011; Schmitt et al., 2011). Social isolation can be seen in children with atopic dermatitis from a young age. This may be adult admonitions regarding scratching for example, that can drive isolation or involve adults and children avoiding those with atopic dermatitis due to perceptions around contagion (Chamlin et al., 2004; Chernyshov, 2016). However, some parents also reported limiting interactions to avoid having to discuss their child’s skin (Chamlin et al., 2004). In an international survey of 2,002 patients and caregivers, 39% of children (aged 8–17) in one study reported being teased or bullied while 24% (aged 2–13 years) and 36% (aged 14–17 years) said atopic dermatitis affects their self-confidence (Zuberbier et al., 2006). This has the potential to affect their relationships as children with severe atopic dermatitis had fewer friends, spent less leisure time with friends, and were less likely to be a member of a sports club (Brenninkmeijer et al., 2009). However, social and leisure activities are affected with all disease severities with 31%, 55% and 86% of patients with mild, moderate and severe atopic dermatitis, respectively, experiencing ‘somewhat’, ‘a lot’ or ‘very much’ affected activities (Paller et al., 2002). Furthermore, 30% (aged 2–13 years) and 46% (aged 14–17 years) of children with atopic dermatitis reported their school life to be affected and missed on average 2–3.5 school days per year due to their condition (Zuberbier et al., 2006). This continued into adolescence with 37% of patients at school not considered to be thriving (Halvorsen et al., 2014).