Advances in the Management of Atopic Dermatitis - Episode 5
Experts reflect on the various comorbid conditions associated with atopic dermatitis and how they can affect patients.
Lawrence Eichenfield, MD: Let’s move on to comorbidities. There’s great literature that’s developed over the past decade on what’s associated with atopic dermatitis and the comorbidities that amplify or complicate the disease and its management. Raj, you’ve done some work on this. Why don’t you tell us about some of the comorbidities that you want to highlight and how you might manage those in practice?
Raj Chovatiya, MD, PhD: Sure. Comorbidities highlight the fact that atopic dermatitis is more than skin deep. There’s a systemic nature to the inflammation that probably causes a lot of the things we’ve seen associated with the disease. It’s nice to think about comorbidities in 2 major buckets. You have atopic or allergic comorbidities, and nonatopic comorbidities.
The atopic comorbidities are things that we all think about, like asthma, hay fever, food allergy, things in the GI [gastrointestinal] realm like eosinophilic esophagitis, the ophthalmology realm, atopic keratoconjunctivitis, and allergic conjunctivitis.
This highlights that there are so many things going on. Sometimes, as dermatologists, we want to focus on the skin, but it helps to take a step back when you’re the quarterback for the care team and do a really good review of systems and medical history every time. You’ll be surprised by the things that come out. That’s how you implement a multidisciplinary team and model for your patients to make sure they’re getting the care they need for all these comorbidities.
Aside from the allergic things, infection—both cutaneous and extracutaneous—is another big 1. With skin infections, we know about superinfection with bacteria or even herpes virus reactivation, but there’s a lot of literature suggesting that there are increased systemic infections, hospitalizations for systemic infections associated with poor outcomes, and higher costs. We talked about some of those sleep disturbances. Not all sleep disturbances are created equal. Sometimes it’s issues getting to sleep, sometimes it’s issues staying asleep, and sometimes it’s issues waking up. There’s a lot of heterogeneity there. Mental health disorders are another big 1. A lot of mental health symptoms are showing strong association in patients with atopic dermatitis, and not just anxiety and depression. ADHD [attention-deficit/hyperactivity disorder] and even suicidality was seen in 1 study that looked at that.
There’s a whole host of literature for things you wouldn’t necessarily think but make sense when you think about the inflammation; everything from musculoskeletal diseases, connective tissue diseases, and even a growing literature on cardiovascular and stroke-related comorbidities. And of course, obesity and metabolic syndrome have touched a lot of diseases as well. This highlights the fact that a lot of caregivers need to be involved with this team, in terms of both the family and health care providers. Mixed messaging, as Peter [Lio] mentioned before, can be an issue. It’s really important to have everybody on the same page when we’re talking about managing someone’s global burden of their disease.
Elizabeth Swanson, MD: The 1 thing I’d throw on there is the growth disturbance that we see in kids with atopic dermatitis. That’s a big deal and sometimes multifactorial. There’s growing evidence that the sleep disturbances might be linked to the growth disturbances because of decreased REM [rapid eye movement] sleep and growth hormone secretion. A lot of these kids are on restrictive diets, either because they should be or shouldn’t be. Eosinophilic esophagitis can cause growth issues too. I’m on the lookout for that and will constantly ask families about that.
Lawrence Eichenfield, MD: Lisa, that’s a great point. We see way more growth failure from inadequate treatment of atopic dermatitis. People are concerned that steroids are going to impact growth, but we have the subset of severe disease where they’re tiny and not thriving until you get that under control. On the other hand, I don’t want to leave comorbidities without saying that we’re a little nervous that there may be concerns that steroids over time, both topical and systemic—but they’re mixed in terms of the history or use—may be responsible for things like cardiovascular morbidity in particular, potential changes in bone status, and osteoporosis. We’ll be doing more studies on comorbidities over time that make us more comfortable with our traditional treatments as well as newer treatments.
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Transcript edited for clarity.