Screening for psychiatric comorbidities!

Screening for sleep disorders, anxiety and depressive symptoms by the treating doctor (GP or specialist) is recommended. There is currently no consistent evidence on whether atopic dermatitis is also linked to a higher risk of cardiovascular disease. The usual preventive measures (including advice on exercise and smoking cessation) can reduce cardiovascular risk in this patient group too.

Sleep disorders are common

Standardised epidemiological data show that fatigue (OR 2.97; 95% CI 2.65–3.34), daytime sleepiness (OR 2.66; 95% CI 2.34–3.01) and insomnia (OR 2.36; 95% CI 2.11–2.64) are more common in people with atopic dermatitis. The one-year prevalence of fatigue is higher in adults with eczema than in a healthy control group (32.8% vs 27.5%) [1]. Sleep disorders can be associated with emotional and behavioural problems, headaches, attention disorders and other health impairments, and, according to the speaker, should be covered in the patient's history [1]. Sleep specialists need to be involved only for patients whose sleep disorders persist even when the skin condition is adequately treated.

Anxiety and depressive symptoms vary

A meta-analysis published in 2018 [2] demonstrated statistically significant associations between atopic dermatitis and depressive symptoms, in adults (pooled OR 2.19; 95% CI 1.87–2.57) as well as in children (pooled OR 1.27; 95% CI 1.12–1.45). For anxiety, data are available only for adults (pooled OR 2.19; 95% CI 1.75–2.73). The statistical analysis also showed positive correlations between atopic dermatitis and suicidality (pooled OR 4.32; 95% CI 1.93–9.66).

As a clinical implication of these findings, the authors conclude that depressive symptoms, anxiety disorders and suicidality should be taken into account when treating patients with atopic dermatitis. Relieving the symptoms of the skin condition alone can also have a positive effect on comorbid mental wellbeing.

According to a case-control study published in 2018, carried out in Canada over ten years among people aged 15 to 55, patients with persistent eczema (five or more eczema-related doctor visits over five years) have a moderately increased risk of suicide. This risk is not independent of general health status and can be reduced by adequate suicide prevention [3].

Cardiovascular disease: a complicated picture

The evidence on a possible correlation between atopic dermatitis and cardiovascular disease is inconsistent. According to Ascott et al., adults with atopic dermatitis have an increased risk of various cardiovascular diseases such as stroke and heart attack, depending on the severity of the atopic symptoms [4]. Epidemiological data from Silverwood et al. likewise indicate that severe atopic eczema in particular is a potential cardiovascular risk factor [5]. Drucker and Harvey postulate an explanatory model in which various mediating variables influence the link between atopic dermatitis and cardiovascular disease (e.g. sleep disorders, depression, smoking, overweight, high blood pressure, lack of exercise) [6].

Source: AAD Annual Meeting 2019, Washington (USA)

References

1. Silverberg JI, et al: Sleep Disturbances in Adults with Eczema Are Associated with Impaired Overall Health: A US Population-Based Study. The Journal of investigative dermatology 2015; 135(1): 56–66).
2. Rønnstad ATM, et al.: Association of atopic dermatitis with depression, anxiety, and suicidal ideation in children and adults: A systematic review and meta-analysis. J Am Acad Dermatol 2018; 79(3): 448–456.e30. doi: 10.1016/j.jaad.2018.03.017.)
3. Drucker AM, Thiruchelvam D, Redelmeier DA: Eczema and subsequent suicide: a matched case-control study. BMJ Open. 2018 Nov 25; 8(11):e023776. doi: 10.1136/bmjopen-2018-023776.).
4. Ascott A, et al.: Atopic eczema and major cardiovascular outcomes: A systematic review and meta-analysis of population-based studies. J Allergy Clin Immunol 2018. Dec 18. pii: S0091-6749(18)32728-3. doi: 10.1016/j.jaci.2018.11.030. [Epub ahead of print].
5. Silverwood RJ, et al.: Severe and predominantly active atopic eczema in adulthood and longterm risk of cardiovascular disease: population based cohort study. BMJ 2018 May 23; 361: k1786. doi: https://doi.org/10.1136/bmj.k1786
6. Drucker AM, Harvey PJ: Atopic dermatitis and cardiovascular disease: What are the clinical implications? J Allergy Clin Immunol 2019 [in press]. [Epub ahead of print]. www.jacionline.org/article/S0091-6749(19)30068-5/pdf
7. Drucker A: Folienpräsentation. Atopic dermatitis comorbidities: what do derms need to know? AAD Annual Meeting 2019, San Francisco March 2, 2019.

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Mirjam Peter, M. Sc.