Children with atopic dermatitis experience ‘worst itch’ in evening
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Children with atopic dermatitis generally experienced the most intense itching in the early evening or bedtime, approximately 3 hours before they fell asleep, according to a study published in Annals of Allergy, Asthma & Immunology.
Brian T. Cheng, BA, an MD candidate in the department of allergy and immunology at Northwestern University Feinberg School of Medicine, and colleagues conducted a cross-sectional survey of 240 parent-child dyads.
The children involved in the study were aged 1 to 17 years and had physician-diagnosed, active atopic dermatitis (AD), reporting scratching at least one night or more in the previous week.
The cohort included 60 children aged 1 to 4 years, 120 children aged 5 to 12 years and 60 adolescents aged 13 to 17 years. Also, 45% were female (n = 107), 36% were white (n = 86), 32% were Black (n = 77) and 83% had moderate to severe AD.
The survey asked parents “Over the past 7 days, what time of day or night was your child’s itch the worst?” Parents also rated the intensity of these itches during the morning, afternoon, evening, bedtime and sleep.
Children aged 8 years and older independently answered survey questions about the time they experienced the worst itch, itch intensity at different times of day and what time they fell asleep, with 133 participants providing data.
Overall, the parent-proxy reported the worst itch occurred at 7 p.m. on weekdays and at 8 p.m. during weekends.
When broken down by age, the parents of the children aged 8 to 17 also reported the worst itch at 7 p.m. on weekends and at 8 p.m. during the weekends. Parents of children aged 1 to 4 years reported the worst itch most often at 6 p.m. and 7 p.m., whereas parents of those aged 5 to 12 years reported it at 7 p.m. Parents of adolescents reported it at 7 p.m., 8 p.m. and 10 p.m.
According to parent-proxy survey results, the worst itch occurred a mean ± standard error of 2.7 ± 0.4 hours before falling asleep on weekdays and 3 ± 0.4 hours before falling asleep on weekends. Children and adolescents reported worst itch as a mean ± standard error of 3.2 ± 0.8 hours before falling asleep on weekdays and 3 ± 0.5 hours before sleeping during weekends.
Also, children aged 8 to 17 years reported experiencing the worst itch at 2 p.m. and 8 p.m. on weekdays and at 7 p.m. during weekends. The researchers attributed this additional peak itch reported by children and adolescents to its occurrence during the school day, when parents would not witness it, and increased stress during the day.
There were increases in the average numeric rating of parent-reported itch intensity in the evening (5.6 vs. 5.4; P = .01) and at bedtime (5.8 vs. 5.4; P < .0001), compared with average itch intensity during the rest of the day. The children reported similar increases in intensity during the evenings (5.3 vs. 5.1; P = .04) and at bedtime (5.4 vs. 5.1; P = .006).
Noting the need for additional prospective studies, the researchers attributed variations in itch intensity by time of day to differences in skin and inflammatory circadian rhythms in childhood AD.
Also, itch may be triggered by evening rituals such as bathing, use of hot water and soap and changes in clothes. Daytime activities may distract children and adolescents from itching as well, the researchers added.
Perspective
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Itching has a profound effect on quality of life in children with AD. In fact, we have published two recent papers on the subject.
Although it is not surprising to find evening as the time of worst itch, which is pretty much what all patients and parents report, it was interesting that it precedes bedtime by about 3 hours.
Doctors should consider recommending that patients apply evening anti-inflammatory medications shortly before that 3-hour time point and ensure that potential triggers of itch, such as hot water in a short bath or exposure to irritants, are minimized.
The peak itch coincides with changes in circadian rhythms, suggesting the need for more research on skin and inflammatory circadian rhythms, as well as improved therapies for itch in general.
References:
- Paller AS, et al. J Invest Dermatol. 2021;doi:10.1016/j.jid.2021.10.015.
- Fang MM, et al. Br J Dermatol. 2021;doi:10.1111/bjd.19541.
Perspective
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Chronic itching, such as that experienced by patients with AD, can have a hugely detrimental impact on quality of life. This is something that may not be fully appreciated by most people who don’t have AD. In addition to the direct suffering that itch causes, it can also negatively affect sleeping, and it is very clear that poor sleep quality can impact all aspects of someone's life for the worse.
Although I don’t think the results of this study are surprising, I do think they are very significant. Understanding when itch is likely to be greatest could help increase awareness and sensitivity for both patients and their parents.
Doctors can use these findings to better educate patients and parents on what to expect when having AD. Patients and parents can then incorporate this better understanding into the way they approach management of their chronic condition.
This research is an important step in understanding the experience of itching in children with AD. One next step could be to use this information to evaluate if the timing of treatments has an impact on itching when it is at its worst.
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