Atopic Dermatitis (Eczema) and Psychological Disorders

Psychological Disorders: –

Depression

Anxiety

Attention Deficit/Hyperactivity Disorder (ADHD)

Autistic Spectrum Disorder (ASD)

Atopic Dermatitis (AD) is a multifactorial, immune mediated, chronic and relapsing skin disease, with significant emotional distress, sleep disturbance and Quality of Life (QoL) difficulties. 1,2,3

Most cases of AD begin in childhood or adolescence, with more than 80% of pediatric patients having persistent symptoms of itch and dry skin in adulthood. The early age of onset and disease chronicity, plus impaired quality of life weighs heavily on a child’s psychological and behavioural development. This often leads to delayed social development throughout life and very high rates of psychological and behavioural disorders.5, The impairment of quality of life caused by childhood AD has been shown to be greater than or equal to other common childhood diseases such as asthma and diabetes, emphasising the importance of AD as a major chronic childhood disease.1,2,3

AD patients have been described with lower self-competence and self-efficacy, when compared with healthy individuals and there is also a clear relationship between the prevalence of a mental health disorder and the reported severity of the skin disease. 1,2,3

Psychological stress and AD symptoms seem to form a vicious cycle. However, the exact mechanism as to how stress affects AD is as yet largely unknown. Evidence suggests that stress stimulates the hypothalamic-pituitary-adrenal (HPA) axis releasing neuropeptides and neurotrophins, which influence the development and course of AD, inducing epidermal barrier dysfunction, and lowering the itch threshold.4

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The current incidence of psychiatric disorders among dermatological patients is estimated at about 30-40% and the association between anxiety and depression, and AD is well documented in scientific and medical journals.1,2,3 AD and clinical depression interact closely, and causal relationships between the two conditions have frequently been observed; e.g. the onset or exacerbation of AD often follows stressful life events such as severe disease in a family member, divorce, or parental separation.5

This may reflect the psychological distress produced by both the stigma associated with visible AD skin lesions and the unpredictability of disease flares, and may be manifested by the high proportion of patients (approx. 60%) who reported being embarrassed by or self-conscious of their skin condition in various studies. The psychological burden can further negatively impact mood and QoL. Thoughts of suicide have been reported in 15% of patients in an AD population in Europe and up to 20% of individuals with severe disease.3

In Dermatology Life Quality Index (DQLI) questionnaires, approximately 46% AD patients report severe pruritus (itch) with almost 15% rating it as unbearable, 86% experience itching every day and approx. 42% state that they itch up to 18 hours per day. Nearly all patients also reported the frequent occurrence of bleeding, oozing, cracking, flaking, or drying of their skin. AD and itching has a significant impact on patient-reported sleep with approx. 68% of patients reporting that itch delayed falling asleep and occasionally or frequently woke them up at night, with up to 36% reporting that their sleep was disturbed every night. Loss of sleep may contribute to daytime sleepiness and fatigue, further reducing functional activities and adversely affecting mood and QoL due to the fact that sleep likely has a reciprocal relationship with mental health.3

Children with AD face a slightly different set of challenges and often have negative self-esteem (subjective perception of self-worth) and poor self-image (subjective perception of abilities, appearance). They experience frustration, fussiness, irritability, unhappiness, loneliness, self-consciousness and emotional sensitivity. Parents have reported that their AD children often cry, and are nervous and insecure. Researchers observed perfectionism, rigid and obsessive thought patterns, anxiety and depression, obsessive and compulsive traits in paediatric AD patients. Children with AD also have difficulties in social interaction and impaired social competence.6

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Sixty percent of children with AD experience sleep disturbance caused by their disease, with 83% reporting sleep disturbance during exacerbations. The sleep of children with eczema was characterized by problems with settling and maintaining sleep while their daytime functioning was characterized by excessive daytime sleepiness and higher ADHD and Oppositional Behaviour scores as well as poor performance in daytime activities, specifically school performance.6 Problematic behavioural patterns that include hyperactivity, impaired attention, scratching to get attention; stubbornness, aggressiveness, disruptive and oppositional behaviour have been documented. A significant association was found between Attention Deficit Hyperactivity Disorder (ADHD) and AD. It is suggested that these behavioural difficulties are possibly mediated by disturbed sleeping patterns, difficulty in coping with the discomfort of AD and its treatment, disfigurement, stigmatisation and disciplinary challenges.7

Various studies have consistently indicated an association between AD and Autism Spectrum Disorder (ASD) and ADHD which is independent of environmental exposures and other comorbidities. Particularly infant AD appears to be associated with later development of ADHD symptoms. Children with previous or prevalent AD have an approximately 43 % increased risk to be diagnosed with ADHD or to display clinical ADHD symptoms.8, 9

It has been speculated that ADHD/ASD symptoms, AD, food hypersensitivity and sleep disruption may be linked by shared pathophysiological factors and that these impairments are characterized by a relevant developmental interplay, especially in early infancy and childhood. Disturbed sleep is a characteristic feature of ASD/ADHD and eczema and may be one mediating factor in the observed associations. However, other mechanisms may also be involved such as genetic or neuro-immunomodulatory mechanisms. It has been suggested that the non-allergic activation of TH1 and TH17 cells, which mediate the inflammatory processes, may be of relevance in the association between AD and ADHD. Also excessive cytokine release may impact on the central nervous system as they are able to pass the blood–brain barrier, thus possibly affecting both neurotransmission and brain circuits which are known to be involved in ADHD and/or affecting the sleep–wake rhythm.8, 9

Recent studies have also linked sleep disturbance to obesity and hypertension (blood pressure PB) in children.  The long-term effect of increased BP are unknown in children, but it is possible that cumulative increases of BP are associated with cardiovascular disease later in life, similar to that observed in psoriasis. The mechanism of association between obesity and AD remains unknown. Previous studies have suggested that adipose (fat) tissue may directly influence the risk of AD. 10  The association between AD and in particular, central obesity – where excessive fat is stored around the stomach and abdomen, in particular, is of major concern. Central obesity has previously been reported to have particularly harmful effects on a variety of medical disorders, including asthma, dyslipidemia, diabetes, coronary artery disease, and myocardial infarction.

 

Also read our BLOGS – Stress, Anxiety, Depression – Atopic Eczema (AE)/Atopic Dermatitis (AD) and associated Itch

Stressed About Your Skin Condition – Identify Your Stressors and Your Stress Responses 

REFERENCES

  • Lewis-Jones S. (2006), Quality of life and childhood atopic dermatitis: the misery of living with childhood eczema. International Journal of Clinical Practice, 60: 984–992. doi:10.1111/j.1742-1241.2006.01047.x
  • Mina, Shaily et al. “Gender Differences in Depression and Anxiety Among Atopic Dermatitis Patients.”Indian Journal of Dermatology 2 (2015): 211.PMC. Web. 20 Oct. 2016.
  • Simpson M.I. et al.; Patient burden of moderate to severe atopic dermatitis (AD): Insights from a phase 2b clinical trial of dupilumab in adults; J AM ACAD DERMATOL MARCH 2016
  • Sang Ho Oh et al.; Association of Stress with Symptoms of Atopic Dermatitis; Acta Derm Venereol 2010 Preview
  • Sewon Kim er al.; The Association between Atopic Dermatitis and Depressive Symptoms in Korean Adults: The Fifth Korea National Health and Nutrition Examination Survey, 2007–2012; Korean J Fam Med 2015;36:261-265
  • Gouws A.; The Impact Of Atopic Dermatitis On The Psycho-Social Wellbeing Of Children And Their Families; Current Allergy & Clinical Immunology, March 2016, Vol 29, No 1
  • Camfferman D et al.; Eczema, Sleep, and Behavior in Children; Journal of Clinical Sleep Medicine, Vol. 6, No. 6, 2010
  • Schmitt J. et. Al.; Association of atopic eczema and attention-deficit/hyperactivity disorder – meta-analysis of epidemiologic studies; Zeitschrift für Kinder- und Jugendpsychiatrie und Psychotherapie (2015), 41, pp. 35-44. DOI: 10.1024/1422-4917/a000208
  • Tzu-Chu Liao et al.; Comorbidity of Atopic Disorders with Autism Spectrum Disorder and Attention Deficit/Hyperactivity Disorder; The Journal of pediatrics · February 2016 DOI: 10.1016/j.jpeds.2015.12.063
  • Silverberg J. I. et al.; Central Obesity and High Blood Pressure in Pediatric Patients With Atopic Dermatitis; JAMA Dermatology February 2015 Volume 151, Number 2