Clinicians may be familiar with well-established associations between atopic dermatitis (AD) and other atopic conditions (eg, asthma, allergic rhinitis) and psychiatric disorders (eg, depression, anxiety). But there is mounting evidence that suggests AD is also associated with a number of comorbidities that further add to its burden of disease—particularly in adults with AD. 

AD can be clinically challenging to manage, due to its chronic nature, unremitting pruritus, and resulting morbidity. More comprehensive treatment plans require awareness of the emergent comorbidities. 

Raising awareness: AAD guidelines

AD typically presents as intense pruritus, pain, sleep disturbances, and anxiety/depression. New research indicates there are additional factors that clinicians must watch out for.

First in a series of publications and comprising 32 statements, new guidelines from the American Academy of Dermatology (ADD) review evidence to raise clinician awareness of comorbidities that may be associated with AD in adults. The objective of the guidelines was to assess the level of evidence for associations between AD and comorbid conditions, with the goal of raising awareness of dermatologists and other clinicians who care for patients with AD. 

To weigh the certainty and overall quality of the evidence, the guidelines utilized the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) to determine strengths of association between AD and comorbidities.

Evidence was classified into three categories—clear or high quality, limited or moderate quality, and inconclusive or low quality. While the guidelines are insightful, they do not make any recommendations on screening or management of identified comorbidities.

Clear evidence of an association

The guidelines found clear evidence of associations between AD and atopic and allergic conditions (eg, asthma, food allergy, allergic rhinitis), immune-mediated conditions (eg, alopecia areata, chronic urticaria), mental health (eg, depression, anxiety, self-harm), bone health conditions (eg, osteoporosis, bone fractures), and skin infections (eg, staphylococcal skin infections, eczema herpeticum, serious cutaneous infections). Interestingly, the guidelines found little evidence to support associations between allergic conjunctivitis and eosinophilic with AD.  

Limited evidence of an association

The guidelines found limited evidence of an association between AD and substance use (eg, alcohol use disorders, cigarette smoking), ADHD, and elements of metabolic syndrome (eg, obesity, dyslipidemia). A small association was found for various cardiovascular diseases (eg, hypertension, peripheral/coronary artery disease, congestive heart failure), but the guidelines noted that a severity gradient may play a role suggesting increased risk of an outcome in adults with more severe AD.

Inconclusive evidence of an association

The guidelines found inconclusive evidence of associations between AD and autism spectrum disorders, myocardial infarction, stroke, and metabolic syndrome as a whole. 

Putting the guidelines into action

Atopic dermatitis is not simply a dermatological disease but one that may be associated with a number of systemic comorbidities. Clinicians must recognize such comorbidities in light of their potentially adverse effects on any contemplated treatment care plan and, at the same time, consider the implications on the patient’s burden of disease.

These guidelines also present an opportunity to educate patients with AD about the potential manifestations of the disease. Such education may help patients take a more proactive role in the shared decision-making process and/or self-management of the disease, as well as potentially reduce healthcare utilization and associated costs.

Guttman-Yassky and colleagues advocate for a structured multidisciplinary care team (eg, dermatology, cardiology, primary care) to address the challenge of managing the complexity of AD and its associated comorbidities. This sentiment is further corroborated by Weidinger and colleagues recognizing the formation of multidisciplinary teams as a “best clinical practice” for treating AD.

Reinforcing these data are results from a 2021 study of real-world comorbidities associated with AD in adults emphasizing the systemic nature of AD while advocating the need for collaborative management. 

References

1. Davis DMR, Drucker AM, Alikhan A, et al. AAD guidelines: awareness of comorbidities associated with atopic dermatitis in adults. J Am Acad Dermatol. 2022 Jan 24. [Epub ahead of print]

2. Guttman-Yassky E, Nosbaum A, Simpson E, Weidinger S. Pioneering global best practices in atopic dermatitis: results from the atopic dermatitis quality of care initiative. Clin Exp Dermatol. 2022;47(2):303-311.

3. Roh YS, Huang AH, Sutaria N, et al. Real-world comorbidities of atopic dermatitis in the US adult ambulatory population. J Am Acad Dermatol. 2021 Nov 18. [Epub ahead of print]

4. Weidinger S, Nosbaum A, Simpson E, Guttman E. Good practice intervention for clinical assessment and diagnosis of atopic dermatitis: findings from the atopic dermatitis quality of care initiative. Dermatol Ther. 2021 Dec 11. [Epub ahead of print]