Comorbidities With Atopic Dermatitis

Lawrence F. Eichenfield, MD: Lisa, can you tell us about some of the emerging information on comorbidities with AD [atopic dermatitis]?

Elizabeth A. Swanson, MD: Definitely. We have the atopic stuff: allergies, asthma, allergic conjunctivitis, and eosinophilic esophagitis. Then we have a lot of the mood and mental stuff: ADHD, anxiety, depression, and even increased suicidality in patients with bad atopic dermatitis. Then we have some of the more questionable things like osteoporosis and osteopenia that might be related to some of the topical steroid management that we’ve used over the years.

Even more recently, there are potential cardiovascular issues and comorbidities that might go along with atopic dermatitis. As we learn more about the condition, we learn more about the things that it might be associated with too.

Lawrence F. Eichenfield, MD: There’s always a mixture of clinical experience and the epidemiology. When we think about infections and taking care of patients with more severe disease, bacterial infection and occasional eczema herpeticum were seen in more severe patients, but they’re also a big part of the disease. We know that when the staph gets bad, the eczema gets bad. When the eczema gets bad, the staph gets bad. You can manage it with good anti-inflammation medicine and antibiotics or both, which is what we tend to do in flaring eczema patients. That’s a comorbidity that’s linked to the physical expression of the disease. Sleep disturbance is a physical expression of itch and rash association.

The epidemiological stuff is much trickier. We do see an increased risk of cardiovascular risks. Then you’re looking at these big data sets and what are called forest plots. The forest plots say, “Here’s 0,” and you’re getting a little nubbin that shows a 1.15 relative risk of an MI [myocardial infarction], which makes you wonder, “Is this important for patients to know?” Osteoporosis is a little higher, and then we have to worry. Is that because of lifestyle? Are patients with atopic dermatitis staying inside? Is it because they’ve had steroids? Hopefully, it’s the oral steroids and not topical. They’ve done it over time. Without further data, people are going to get more phobic about using topical agents. 

The comorbidity issue is dynamic right now. We don’t want to overstate it. On the other hand, we have learned a lot; especially how more significant disease affects the individual, just to put that into context for people who want to be skeptical about groups saying their disease is really powerful. Don’t forget that we used to have about a 5% prevalence of atopic dermatitis in kids in most industrialized countries 30 or 40 years ago, and now we’re up to 12% to 15%.

There are more people who have AD. Even if we had the same rate of people outgrowing it—and we think we probably overstated that—it leaves a lot more people with persistent disease and also more people who have moderate to severe disease who end up collecting more of the comorbidities. 

Elizabeth A. Swanson, MD: Another comorbidity that I don’t think gets talked about a ton is growth disturbance. There was a study, maybe in JAAD [Journal of the American Academy of Dermatology], in 2018 showing that sleepless nights might have something to do with that. When kids with atopic dermatitis sleep, they don’t sleep as well and don’t enter REM [rapid eye movement] as long or as often. It’s during REM sleep that growth hormone is secreted, so physiologically, these kids with severe atopic dermatitis are getting less growth hormone. We’ve all noticed that in our patients. Many kids with bad AD will be small for their age. That’s an important comorbidity too.

Lawrence F. Eichenfield, MD: That is something that, especially in the first few years of life—I don’t think I’ve ever seen growth failure from overuse of topical corticosteroids, but I’ve seen lots of growth failure from inadequate control of atopic dermatitis. This is 1 of those issues they deal with. 

Jeffrey M. Bienstock, MD, FAAP: That’s an important point. In primary care, we talk about that with asthma as well. If we can’t control your asthma, your child is going to be sick. If they’re going to be sick, they’re not going to sleep. Don’t worry so much about an inhaled corticosteroid to help their breathing because in the long run, they’ll be healthier, and they will attain full height. I have a son just like that who is about 6 inches taller than his brother. He was on inhaled corticosteroids, worried that he wasn’t going to grow. Lo and behold, he beat out his brother by 6 inches.

Lawrence F. Eichenfield, MD: We do have the occasional case in infancy where we have a real failure-to-thrive picture with hypoproteinemia and hypoalbuminemia. It’s actually written about a lot in the Japanese literature. Basically, it’s inadequate intake. Partially, that sometimes happens because patients are avoiding foods they think are allergenic. Sometimes it’s just the sequence. So if they think something might be allergenic, they avoid it, and they end up working themselves into a situation in which the child can’t keep up and the eczema ends up being a further aspect. Don’t forget that you can have gut leakage associated with it and gut leakage associated with true food allergy, which can be seen in early AD.

Transcript Edited for Clarity