Furthermore, according to Su et al,23 the costs of AD are related to disease severity. Moreover, their data suggest that among chronic childhood diseases, the financial burden of AD is greater than the cost of asthma and similar to the cost of diabetes mellitus.23
Association Between QOL and Disease Severity
A large observational study found that improvement in AD severity was followed by an increase in QOL.24 A positive correlation between disease severity and QOL has been found in other studies,25,26 though no correlation or only moderate correlation also has been reported.27 Apparently, in addition to QOL, disease severity scores are substantial parameters in the evaluation of distress caused by AD; the HOME initiative has identified clinician-reported signs and patient-reported symptoms as 2 of 4 core outcomes domains to include in all future AD clinical trials.3 For measuring symptoms, the Patient-Oriented Eczema Measure (POEM) is the recommended instrument.28 Regarding clinical signs, the HOME group named the Eczema Area and Severity Index (EASI) as the preferred instrument.29
Psychological Burden
Stress is a triggering factor for AD, but the connection between skin and mind appears bidirectional. The biological reaction to stress probably lowers the itch threshold and disrupts the skin barrier.30 The Global Burden of Disease Study showed that skin diseases are the fourth leading cause of nonfatal disease burden.31 There are several factors—pruritus, scratch, and pain—that can all lead to sleep deprivation and daytime fatigue. Based on our experience, if lesions develop on visible areas, patients can feel stigmatized, which restricts their social life.
The most common psychological comorbidities of AD are anxiety and depression. In a cross-sectional, multicenter study, there was a significantly higher prevalence of depression (P<.001) and anxiety disorder (P=.02) among patients with common skin diseases compared to a control group.32 In a study that assessed AD patients, researchers found a higher risk of depression and anxiety.33 Suicidal ideation also is more common in the population with AD32,34; a study showed that the risk of suicidal ideation in adolescents was nearly 4-fold in patients with itching skin lesions compared to those without itch.34
According to Linnet and Jemec,35 mental and psychological comorbidities of AD are associated with lower QOL, not with clinical severity. As a result, to improve QOL in AD, one should take care of both dermatological and psychological problems. It has been demonstrated that psychological interventions, such as autogenic training, cognitive-behavioral therapy, relaxation techniques, habit reversal training,36 and hypnotherapy37 might be helpful in individual cases; educational interventions also are recommended.36 With these adjuvant therapies, psychological status, unpleasant clinical symptoms, and QOL could be improved, though further studies are needed to confirm these benefits.
Conclusion
Atopic dermatitis places a notable burden on patients and their families. The degree of burden is probably related to disease severity. For measuring QOL, researchers and clinicians should use validated methods suited to the age of the patients for which they were designed. More studies are needed to assess the effects of different treatments on QOL. Besides pharmacotherapy, psychotherapy and educational programs might be beneficial for improving QOL, another important area to be studied.