Does the burden of atopic dermatitis vary by age, race, ethnicity?

By Kathryn Schwarzenberger, MD, December 1, 2019

In this month’s Clinical Applications column, Physician Editor Kathryn Schwarzenberger, MD, talks with Jonathan Silverberg, MD, PhD, MPH, about his recent Dermatitis article, "Conceptual Model to Illustrate the Symptom Experience and Humanistic Burden Associated With Atopic Dermatitis in Adults and Adolescents," as well as Joy Wan, MD, MSCE, and Junko Takeshita, MD, PhD, MSCE, about their JAMA Dermatology paper, "Racial and Ethnic Differences in Atopic Dermatitis–Related School Absences Among U.S. Children."

Dr. Schwarzenberger: Dr. Silverberg, the study by you and your colleagues sought to “explore and document in depth the adult and adolescent experience of AD.” How is this study unique and is there any new information you are seeking?

Dr. Silverberg: AD has a very heterogeneous complex of signs and symptoms that is often underappreciated by clinicians. This study sought to comprehensively summarize the complexities of AD into a conceptual model that can inform clinicians in practice and how to best assess the burden of AD in research. In addition, few studies have examined the burden of AD in adolescents. This study used mixed methods of reviewing the extant literature as well as extensive qualitative patient interviews to understand the burden of atopic dermatitis in adults and adolescents. A key element of this study is the patient-centricity (i.e., directly interviewing patients to understand their burden of disease).

Dr. Schwarzenberger: Based on your study results, do you think the impact of atopic dermatitis on an adolescent is the same as that of adults? Is there anything unique we should be watching for in caring for teenagers with atopic dermatitis?

Dr. Silverberg: Yes and no. Many of the impacts of AD affected similar proportions of adolescents and adults. However, there were some key differences observed between adolescents and adults. First, skin cracking, pain, burning, flaking, bumps, peeling, scabbing, hardening, and heat/warmth were reported more commonly in adolescents than adults. Whereas, skin scaling, thickening, tightening, crusting, oozing/weeping, blisters, fissures/lesions, and thinning, as well as skin sensitivity and sensitivity to sun were reported more commonly in adults than adolescents. These differences may reflect age-related differences in the clinical phenotype of AD and/or how different aspects of AD can impact patients’ lives. It is noteworthy that adolescents with AD very commonly reported symptoms related to skin pain, including burning and heat/warmth. We previously demonstrated that skin pain is a common and burdensome symptom in adults with AD. This study suggests that skin pain occurs even more commonly in adolescents with AD.

Dr. Schwarzenberger: There were several signs and symptoms of atopic dermatitis that patients described that your physician experts seemed to either not identify or identified with a lower frequency. Do you think this was an artifact of interviewing few experts, or do you think that we, as physicians, may not fully appreciate the impact of atopic dermatitis on our patients?

Dr. Silverberg: Probably a little of both. AD is a complex disease with many different signs and symptoms. It may be challenging assessing all of those from physician experts in a relatively brief research interview. On the other hand, clinicians in the trenches often have limited time to spend exploring the full burden that chronic inflammatory skin disease in general, and AD in particular, can have on patients. Consequently, there may be limited awareness of the importance of certain symptoms in AD. For example, prior to publishing the abovementioned studies on the importance of skin pain in AD, skin pain was not on many physicians’ radar as being important in AD. I hope clinicians’ awareness improved over time now that we have numerous studies confirming the commonality and burden of skin pain in AD. As more research is being conducted in AD, I think we will continue to learn much more about this disease.

Dr. Schwarzenberger: Drs. Wan and Takeshita, your study addresses racial and ethnic differences in atopic dermatitis-related school absences among U.S. children. Thank you for looking at this very important topic. Can you briefly describe your study and your findings?

Drs. Wan and Takeshita: We used data from the Pediatric Eczema Elective Registry (PEER), which is a cohort of children with atopic dermatitis from across the U.S. At the time that participants enrolled into the PEER registry, they completed questionnaires that asked about school absences due to AD in the preceding six months. Using these questionnaire data, we conducted a cross-sectional study of baseline data at the time of registry enrollment to evaluate if AD-related absences differed by race/ethnicity.

Among the 7,272 children enrolled in school or daycare, a total of 241 (3.3%) children reported six or more missed school days in the last six months. When we examined absences by race/ethnicity, we found that non-Hispanic black children and Hispanic children were 1.5-fold and 3.4-fold more likely to have missed at least six days of school because of their skin disease, respectively, after accounting for sex, age, household income, atopic dermatitis disease control and disease duration, other atopic illnesses, and health care visits for atopic dermatitis. The relative differences among the three racial/ethnic groups were also more marked than, and in slight contrast to, the background rates of chronic school absenteeism overall in the U.S., which are highest among non-Hispanic black children (17%) followed by Hispanic children (14%) and non-Hispanic white children (13%). Together, these findings suggest the presence of racial/ethnic disparities in school absenteeism specifically related to AD.

Dr. Schwarzenberger: Was there anything in particular that prompted this study?

Drs. Wan and Takeshita: This work was prompted by existing data that indicate that, compared to white children, black children are more likely to develop atopic dermatitis and have more severe disease. We also collaborated on a study that identified disparities in health care utilization among children with atopic dermatitis. We found that minority children are more likely to seek care from a primary care provider or the emergency room for their skin disease than white children, and, particularly among those with poorly controlled disease, black children are less likely to see a dermatologist than white children.

Knowing these health and health care disparities related to childhood atopic dermatitis, we wanted to know what impact atopic dermatitis may have on other aspects of children’s lives, such as school attendance, and whether the impact also differs by race/ethnicity. While atopic dermatitis has been shown to negatively impact quality of life and lead to school absence, the latter had not been fully characterized in previous studies. The impact of atopic dermatitis on education is of particular interest to Dr. Wan who is a pediatric dermatologist and researcher who studies the psychosocial and life impacts of childhood atopic dermatitis. Racial/ethnic and other disparities in atopic dermatitis and disease impact is of particular interest to Dr. Takeshita whose research program is dedicated to identifying, understanding, and eliminating health and health care disparities in chronic inflammatory skin diseases. Therefore, together, we sought to identify the patient characteristics and other factors associated with greater school absenteeism in children with atopic dermatitis.

Dr. Schwarzenberger: What factors do you think may be at play here and how can we move forward as a specialty to better understand and, hopefully, mitigate these differences?

Drs. Wan and Takeshita: While we identified differences that suggest disparities in school absenteeism rates among black and Hispanic children compared to white children with atopic dermatitis, we are unfortunately unable to identify why these differences exist from this study. Drawing on existing data among other chronic inflammatory diseases, one possible explanation may be that atopic dermatitis has greater negative impact on quality of life among racial/ethnic minority children compared to white children, which in turn, may directly affect school attendance. However, we have not specifically studied this.

Nevertheless, we know that children who are chronically absent from school are more likely to fall behind or drop out, leading to worse socioeconomic and occupational outcomes in the long term. It is thus important for us, as medical practitioners, to ask our patients how their skin disease is affecting daily functions, such as school or work attendance, and to work actively to address these effects. Our study suggests that racial/ethnic minority children may be more vulnerable to the effects of atopic dermatitis with respect to school attendance, but additional research is needed to better understand the drivers of these differences so that measures can be taken to eliminate health and health care disparities in our field.

Dr. Silverberg serves as adjunct associate professor of dermatology and medical social sciences in the Department of Dermatology at the Feinberg School of Medicine at Northwestern University. Dr. Silverberg has received honorarium from AbbVie, AnaptysBio, Arena, Asana Biosciences, LLC, Dermavant, Dermira, Eli Lilly and Company, Galderma Research & Development, LLC, GlaxoSmithKline, Glenmark Generics Inc., Kiniksa Pharmaceuticals, Ltd., Leo Pharma Inc., Medimmune, Menlo Therapeutics, Pfizer Inc., Realm Therapeutics, Inc., Regeneron, and Sanofi-Genzyme, and has been a speaker for Regeneron and Sanofi-Genzyme. His article appeared in Dermatitis.

Dr. Wan is a dermatologist with the Dermatology Section at Children’s Hospital of Philadelphia and is an instructor of dermatology at the Department of Dermatology at the Perelman School of Medicine at the University of Pennsylvania. Dr. Wan receives a research grant from Pfizer Inc. (to the Trustees of the University of Pennsylvania) for work that is unrelated to this manuscript.

Dr. Takeshita serves as assistant professor of dermatology in the Department of Dermatology and assistant professor of epidemiology in the Department of Biostatistics, Epidemiology and Informatics at the Perelman School of Medicine at the University of Pennsylvania. Dr. Takeshita receives a research grant from Pfizer Inc. (to the Trustees of the University of Pennsylvania) for work that is unrelated to this manuscript and has received payment for continuing medical education work related to psoriasis that was supported indirectly by Eli Lilly and Novartis.

Their article appeared in JAMA Dermatology.

Disclaimer: The views and opinions expressed in this article do not necessarily reflect those of DW.

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