Emerging data strongly suggest that children with atopic dermatitis are at increased risk for attention-deficit/hyperactivity disorder.
"The first paper was actually a really good paper, but it was just one study and so we did not quite believe it. But now there’s a confirmatory study by a separate group with really big data," Dr. Lawrence K. Eichenfield said at the Hawaii Dermatology Seminar sponsored by Global Academy for Medical Education/Skin Disease Education Foundation.
In addition, the second study pointed to a possible higher risk of autism in children with atopic dermatitis, and it also confirmed other reports of increased rates of depression and anxiety, noted Dr. Eichenfield, professor of clinical pediatrics and medicine at the University of California, San Diego, and chief of pediatric and adolescent dermatology at Rady Children’s Hospital, also in San Diego.
Atopic dermatitis is the most common chronic inflammatory condition in childhood. Attention-deficit/hyperactivity disorder is the most common psychiatric disorder. The first study to report an association between the two was a German, case-control, population-based study involving 1,436 atopic dermatitis patients aged 6-17 years and an equal number of age- and gender-matched controls without the skin disease.
The prevalence of diagnosed ADHD was 5.2% in the atopic dermatitis patients and 3.4% in controls (P = 0.02). In a multivariate logistic regression analysis, atopic dermatitis was an independent predictor of prevalent ADHD, with an associated 47% increased risk of the psychiatric disorder compared with youths without atopic dermatitis. Moreover, there was a suggestion that the more severe a patient’s atopic dermatitis, the greater the likelihood of comorbid ADHD, since the likelihood of ADHD increased with each additional physician visit for atopic dermatitis (JAMA 2009;301:724-6).
More recently, in a study presented at a major meeting but not yet published, Dr. Eric L. Simpson and his coinvestigators at Oregon Health and Science University, Portland, confirmed the initial German finding that pediatric atopic dermatitis is associated with ADHD, this time in a database of 90,000 U.S. children. Once again, the more severe the skin disease, the greater the risk of ADHD. In this study, atopic dermatitis was also associated with increased risks of depression, anxiety, and autism.
Possible mechanisms underlying the observed association between atopic dermatitis and comorbid psychiatric conditions include sleep disturbance – a prominent feature in atopic dermatitis – and systemic inflammation, according to Dr. Eichenfield.
The well-established atopic comorbidities associated with atopic dermatitis are asthma, allergic rhinitis, and food allergy. Dr. Eichenfield said that he welcomes the evolving evidence of psychologic comorbidities for the opportunity it provides to encourage treatment adherence. Like other treating physicians, he finds topical steroid phobia to be a huge problem.
"I actually use this information in my clinical practice as a way to get my families to adequately treat atopic dermatitis," he said. "If I have families that are very steroid phobic, I’ll say, ‘You know, you really want to treat your kid with appropriate topical therapy to minimize the disease impact: to minimize the sleep disturbance and potentially minimize the neurobehavioral impact of atopic dermatitis.’ I use that as a tool to stay with our regimens of care."
Steroid phobia is a problem worldwide, not just in the United States. For example, Dr. Eichenfield noted that when French dermatologists recently surveyed 208 consecutive atopic dermatitis patients or their parents using a detailed 69-item questionnaire, 81% reported having fears about topical corticosteroids – the mainstay of atopic dermatitis treatment – and 36% admitted to treatment nonadherence as a result of their worries. Fears did not correlate with disease severity (Br. J. Dermatol. 2011;165:808-14).
"I think that in all of dermatology there’s probably no greater chasm between where our families are at in terms of concerns about a medication and where we are as physicians in terms of not having concerns than in the area of topical steroids for atopic dermatitis," Dr. Eichenfield said.
He noted that he makes extensive use of parental educational handouts and written action plans in addition to face-to-face discussion of safety concerns at the time he prescribes topical steroids. One strategy that he’s recently realized makes a big difference in terms of adherence is to explain carefully that the midpotency topical steroids used in treating atopic dermatitis – as distinct from potent and superpotent topical steroids – do not have the side effects and systemic absorption issues steroid-phobic parents are worried about.
Another effective strategy is to be very specific about the quantity of topical medication he wants the patient to use for flare control.
"Instead of saying, ‘Twice a day application of a midstrength topical steroid for 2 weeks,’ now I’ll say, "I would like you to use up this 80-g tube in the next 2 weeks and then I’ll see you back – and it’s safe to use this amount for this particular length of time.’ I find that makes a huge difference in terms of outcomes if I explain it that way," Dr. Eichenfield said.