Challenges of Treating Atopic Dermatitis in Children

Julie Block: There are many challenges for adolescents with atopic dermatitis. Come on, that’s the age you just want to fit in and be like your peers, and you’re not. First you have the visible signs, which many teens tell us over and over again they will do anything to cover up. In the summer time, they’re wearing shoes, they never wear sandals, they never wear shorts, they never wear short sleeves. So that is part of the appearance part.

Now, on the psychosocial aspect, many are unable to do the things that they love—play sports, be in the plays because the clothes and costumes or makeup itch, do fun things with their friends, go out to eat. If they have food restrictions, it’s limited. And their feelings of self-worth, their feelings of isolation. We know it’s very well documented how much children with atopic dermatitis are bullied. So they feel quite isolated, and that has a snowball effect, obviously, on their overall well-being. Many children are home schooled in their younger years. Some in high school wish they were home schooled because they don’t want to go. With severe disease, you may miss a lot of school, so your academics are impacted, and you may not be able to keep up like you’d like. But I think for teens especially, the name of the game at that age is really “just want to be normal. I want to fit in.” And with moderate to severe disease, it’s anything but normal.

Elaine Siegfried, MD: Is atopic dermatitis more than skin deep is the question. And now that we have the opportunity to see how targeted therapy works, that’s becoming much more obvious to us. I think that for any disease the practitioners who see people who are affected with that disease see it differently. If you’re a skin doctor, you look at the skin, you know? If you’re a pulmonologist, you look at the lungs. Allergists I think are better at seeing a whole person. But you know atopy is not just one disease, it’s a group of disorders that reflect this immune dysregulation. And so atopic dermatitis I think is part of that, but it’s not the only part. There are definitely extracutaneous problems that are happening in people who have eczema. It’s just that the eczema causes the most disruption in their life.

Julie Block: There can definitely be underlying inflammation without visible signs of the disease, without the flares and the redness. Science is telling us new information about the systemic inflammatory nature of atopic dermatitis. And we know from patients who tell us that they may not have visible flares, but they will be scratching crazy all night, all day. So you would suspect that that would be inflammation under the skin.

Elaine Siegfried, MD: Asthma, hay fever, allergic conjunctivitis are all comorbidities that are well described in association with atopic dermatitis. A smaller percentage of people have a hidden but really important type of inflammation that’s eosinophilic gut disease, eosinophilic esophagitis, and eosinophilic gastroenteritis that in children can present with just poor growth.

People with atopic dermatitis don’t sleep. Sleep is an unknown horizon I think, and there’s a lot of work that of course is being done with sleep. There’s a whole medical specialty that’s geared and focused toward sleep abnormalities. But disrupted sleep in atopic dermatitis may account for the majority of mental health problems that we see. And now that we have targeted treatment for many people, some of their profound mental health symptoms seem to really disappear. So it’s got to be associated with that. But not for everyone. I think it’s that sleeplessness and a noxious stimulus like chronic itch probably aggravate underlying mental health abnormalities as well. But now that we know a little bit more about the epidemiology of that, we’re finding that mental health problems in this population of people is way higher than we used to think.

Julie Block: The known comorbidities for atopic dermatitis are asthma, allergies, allergic rhinitis. Also now we know a little bit more about mental health, including depression, anxiety. Given the new science about the inflammatory nature of this disease, the systemic inflammation, we’re now looking at some cardiac possibilities as comorbidities for this disease. I think for children, ADHD [attention-deficit/ hyperactivity disorder] has also been associated with atopic dermatitis, and we’re learning a lot more about the impact of sleep deprivation, which is, behind itch, the most bothersome symptom of the disease. Sleep deprivation can really affect, obviously, concentration and mood. And I think science and research are leading us to understand a lot more about how that impacts our health.