Atopic Dermatitis (Eczema) and Psychological Disorders

skinconditionsblogcategory

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

Atopic_1

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

Atopic_2

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

ATOPIC DERMATITIS (ECZEMA) AND COMORBIDITIES

blog-link-post-img

Atopic dermatitis (AD), also known as atopic eczema, is a chronic inflammatory disorder that causes significant morbidity and has a wide range of allergic and non-allergic comorbid disorders.

Comorbidity is a concurrence of multiple diseases or disorders in association with a given disease. The patient with AD has an increased risk of developing one or more of a number of other diseases/conditions that share many immunological features with AD.

 CHART 1: Comorbidities Associated with AD

Cutaneous (skin) infections including:-

Bacterial – Staphylococcal   / Impetigo contagiosum

Viral – eczema herpeticum

Fungal

 

Other Skin Conditions:

Vitiligo

Psychological and Psychiatric Disorders – Depression

Anxiety

Attention Deficit/Hyperactivity Disorder (ADHD)

Autistic spectrum disorder (ASD)

Food Allergies/Intolerances Cardiovascular Disease – Arterial hypertension/ Atherosclerosis

Stroke

Prediabetes

Diabetes

Obesity

Fatty Liver

Dyslipidemia (Raised cholesterol)

Allergic conjunctivitis

Cataracts 

Atopic keratoconjunctivitis (AKC) 

Allergic rhinitis

Hayfever

Asthma

Acute upper respiratory infection

Acute pharyngitis

Fatigue, insomnia  

1, 2, 3, 4, 5, 6, 7

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, secondary to AD weigh heavily on a child’s psychological and behavioural development, with delayed social development throughout life and very high rates of psychological and behavioural disorders and quality-of-life impairment.6 Various studies have consistently indicated an association between AD and ADHD which is independent of environmental exposures and other comorbidities. Particularly infant AD appears to be associated with later development of ADHD symptoms. Sleeping problems due to AD are suggested as playing an important role for the observed association between AD and ADHD. Children with previous or prevalent AD have an approximately 43 % increased risk to be diagnosed with ADHD or to display clinical ADHD symptoms.8

Researchers have found that adults with AD have higher rates of cigarette smoking, consumption of alcoholic, lower rates of exercise, and higher classification of obesity with category II / III consistently indicated in children and adults, hypertension, prediabetes, diabetes, and high cholesterol.6, 7

staph-infection

Bacterial superinfection by staphylococcal aureus is the most common complication in atopic dermatitis and is almost always present in AD flares.  S. aureus is an important human pathogen that causes a variety of  infections ranging from localised skin and soft-tissue infections (SSTIs) to severe necrotising fasciitis and life-threatening infections.7 , 8  S. aureus can be isolatedfrom 55–75% of unaffected AE skin, 85–91% of chronic lichenified lesions and 80–100% of acute exudative skin lesions.9 The correlation between AD severity and colonization with S. aureus has already been well documented, and it is generally known that this colonization is an important mechanism involved in the continued aggravation of the disease in patients.

S. aureus has shown a capacity to develop resistance to antimicrobials that were originally active against the species. In 1961, there were reports of strains that were methicillin resistant, and they were called methicillin-resistant Staphylococcus aureus (MRSA). By 1980, MRSA strains became an endemic problem in hospitals in several countries. Reports on MRSA infections in AD patients have been published since 2005. Some authors suggest that MRSA should be considered when patients with AD present with more intense and generalized erythemas (redness of the skin), and with the predominant location of infection in these patients being the face, and a fetid (fishy) odour present. Studies worldwide suggest that the prevalence of MRSA in the population with AD varies from 0 to 30.8% depending upon the country of research.10

Colonization by streptococcus generally precedes the development of impetignized lesions (by about 10 days). Group A streptococci often colonize the pharynx of asymptomatic people, especially school-age children. In cases of infected atopic dermatitis lesions, a high prevalence of co-infection by staphylococci and streptococci was reported, and these bacteria were present in about 70 to 85% of patients. B-hemolytic streptococci are the main cause of impetigo and are more commonly isolated on the skin of people with AD than on the skin of healthy individuals or of those with other skin diseases.11

Eczema herpeticum (EH) is caused by Herpes simplex virus-1 (HSV-1), Herpes simplex virus-2 (HSV-2), Herpes zoster virus, Coxsackie virus, etc. Also, EH may occur in children who have AD after smallpox vaccination. If corticosteroid therapy is used in these patients because of misdiagnosis, the lesions may worsen. Therefore, if skin lesions or another pre-existing dermatitis is aggravated after varicella (smallpox) infection then EH must be considered and antiviral therapy must be started immediately.11

AD, is an immunoglobulin E (IgE)-mediated disease with a complex etiology (cause) that is accompanied by superficial inflammation and itchy rashes. An association with asthma and Allergic rhinitis (Hayfever) is well documented. Fifty percent of all those with AD develop other allergic symptoms within their first year of life. In the International Study of Asthma and Allergies in Childhood (ISAAC), among the 56 countries, the prevalence of AD in children varied significantly from 0.3% to 20.5% but shows consistent trends in increasing disease prevalence over time. The main risk factors for progression and persistence of asthma are early onset, IgE sensitization, and severity of AD. Approximate 70% of patients with severe AD develop asthma compared with 20-30% of patients with mild AD and approximately 8% in the general population. Epidemiologic studies have consistently demonstrated strong associations between rhinitis and asthma. Recent clinical and basic science evidence indicated that the two diseases share anatomical, physiological, immuno-pathological, and therapeutical factors. Allergic rhinitis is an inflammatory condition affecting nasal mucosal membranes. In sensitized individuals, allergens such as pollens, moulds, and animal dander provoke this allergic response.12, 13

The relationship between food allergy and AD is complex and the presence of food sensitization and allergy earlier in life predicts a prognosis of severe AD. Around 50–70% of children with an early onset of AD are sensitized to one or more allergens. These are mainly food allergens (cow’s milk, hen’s egg and peanuts being the foods most frequently involved). Food allergy is actually much more common in children with AD with studies reporting ranges from 20 to 80% of children being affected.12,13

Allergic conjunctivitis (AC), either seasonal and/or perennial, is one of the most common types of ocular inflammation which causes redness and swelling of the eyes. Estimates vary, but these types of allergy are said to affect at least 15–20% of the population and higher incidences in those with AD. Its pathophysiology also involves a type I IgE-mediated immune reaction triggered by allergens contacting surface of the eye.2 Atopic keratoconjunctivitis (AKC) is a bilateral chronic inflammatory disease of the ocular surface and eyelid. Its pathomechanism involves both a chronic degranulation of the mast cell mediated by IgE, and immune mechanisms mediated by Th1- and Th2-lymphocyte derived cytokines. It is considered the ocular counterpart of AD. Eczematous lesions may be found on the eyelids, or any place on the body. Skin lesions are red and elevated. They often occur in the antecubital (inner elbow) or popliteal (behind the knees) regions. Typically, eczematous lesions are itchy, and scratching them makes them itchier. Ocular findings vary. The eyelid skin may be chemotic (inflamed eyelid) with a fine sandpaper-like texture. There may be mild, or severe, red and swollen eyes.14

If you have any questions please do not hesitate to contact our clinic by either emailing us at info@goodskincare.com.au or message us on our Facebook page https://www.facebook.com/PsoriasisEczemaClinic/

 

 REFERENCES

  • Simpson EL.; Comorbidity in Atopic Dermatitis; Curr Dermatol Rep. 2012 March 1; 1(1): 29–38. doi:10.1007/s13671-011-0003-5
  • Augustin M. et al.; Epidemiology and Comorbidity in Children with Psoriasis and Atopic Eczema; Dermatology 2015;231:35–40 DOI: 10.1159/000381913
  • Deckert S. et al.; Nonallergic comorbidities of atopic eczema: an overview of systematic reviews; Allergy 69 (2014) 37–45 © 2013
  • Ellis CN. et al.; Validation of Expert Opinion in Identifying Comorbidities Associated with Atopic Dermatitis/Eczema; Pharmacoeconomics 2003; 21 (12)
  • Gradman J. et al.; Allergic conjunctivitis in children with asthma, rhinitis and eczema in a secondary outpatient clinic.
  • Silverberg J.I.; Eczema and cardiovascular risk factors in 2 US adult population studies; J Allergy Clin Immunol 2015;135:721-8.
  • Silverberg J.I. and Silverberg N.B.; Atopic Dermatitis: Update on Pathogenesis and Comorbidities
  • Baviera G. et al.; Staphylococcus Aureus And Atopic Dermatitis: Which Came First, The Chicken Or The Egg?; EMJ Dermatol. 2015;3[1]:92-97.
  • Leung DYM.; The role of Staphylococcus aureus in atopic eczema; Acta Derm Venereol 2008; Suppl 216: 21–27
  • Petry V. et al.; Bacterial skin colonization and infections in patients with atopic dermatitis; An Bras Dermatol. 2012;87(5):729-34.
  • Celtik C. et al.; A Life-Threatening Condition In A Child With Chicken Pox: Eczema Herpeticum; Open Journal of Pediatrics 1 (2011) 1-3
  • Tao Zheng et al.; The Atopic March: Progression from Atopic Dermatitis to Allergic Rhinitis and Asthma; Allergy Asthma Immunol Res. 2011 April;3(2):67-73. doi: 10.4168/aair.2011.3.2.67
  • Nutten S.; Atopic Dermatitis: Global Epidemiology and Risk Factors; Ann Nutr Metab 2015;66(suppl 1):8–16
  • La Rosa M. et al.; Allergic conjunctivitis: a comprehensive review of the literature; Italian Journal of Pediatrics 2013, 39:18 http://www.ijponline.net/content/39/1/18