Atopic dermatitis severity, risks, comorbidities vary across China

Key takeaways:

• Allergic rhinitis and hypertension were the most common comorbidities with atopic dermatitis.
• Foods, seasonal changes, and psychology were found to be aggravating factors.

In order to better manage symptoms of atopic dermatitis, health care professionals must consider aggravating factors and systemic immunotherapy, according to a study published in the Chinese Medical Journal.

These findings can guide treatment strategies as well as help providers monitor the trends and changes in the clinical characteristics of AD while also improving patient management and facilitating future studies, Jiahui Zhao, PhD, MD, associate professor in the department of dermatology, Peking University First Hospital and the Beijing Key Laboratory of Molecular Diagnosis on Dermatoses, National Clinical Research Center for Skin and Immune Disease, and colleagues wrote.

Study design

The cross-sectional epidemiological study included 205 hospitals across 30 provinces in China. It recruited 16,838 participants (mean age, 30.9 ± 24.1 years; 54.91% men) with AD from August 2021 to September 2022.

Participants were evaluated by dermatologist-led surveys for medical histories, including family history and allergies, hay fever and asthma incidence; comorbidities; and AD severity.

To evaluate severity of AD, dermatologists used baseline Investigator Global Assessment (IGA) and the Eczema Area and Severity Index (EASI) scores. Participants were then classified based on IGA scores to determine AD severity.

For comorbidities, researchers collected information on each participant’s prevalence of illnesses related to metabolism and common atopic comorbid diseases. To identify aggravating factors of AD, researchers asked participants to complete information from a predetermined list provided by dermatologists.

To determine pruritus intensity, AD disease control, quality of life and mental health, participants completed the Numeric Rating Scale Itch Intensity, Atopic Dermatitis Control Tool, Dermatology Life Quality Index, Hospital Anxiety and Depression Scale and Sleep Disturbance Score questionnaires, respectively.

Participants also provided information on their individual AD treatment plans from a list of treatments that included topical therapies, traditional systemic therapies, phototherapies, targeted therapies, anticonvulsants and central nervous system depressants.

Results

AD severity was mostly moderate (49.51%), followed by mild (35.72%) and severe (14.77%).

Fewer females presented with severe AD cases vs. men (12.14% vs. 16.91%).

The proportion of patients with severe AD increased with age, with severe AD affecting less than 10% of infants and preschoolers; 10% to 20% of children, adolescents and adults; and 26.56% in older adults. The greatest proportion of severe AD cases was in adults who incurred AD onset at age 60 years or older (26.73%). Further, these proportions of severe AD cases increased more in males vs. females.

No comorbidities were reported in 9,906 (60.95%) participants, whereas 4,717 (29.02%) reported one comorbid disease and 1,631 (10.03%) reported more than one.

Allergic rhinitis had the highest prevalence among the group with one comorbidity, followed by food allergies, asthma, chronic urticaria and drug allergies. Among the severe AD group, significantly more participants reported having asthma and food allergies vs. other comorbidities. Moderate AD participants had a significantly higher rate of allergic rhinitis, and mild AD patients had a significantly higher rate of chronic urticaria.

There also was a significant association between chronic urticaria and a protective effect against moderate and severe AD (OR = 0.74; 95% CI, 0.63-0.87), whereas food allergies may serve as a risk factor (OR = 1.21; 95% CI, 1.06-1.37).

Hypertension had the highest prevalence among participants with at least one nonatopic comorbidity related to metabolism, followed by diabetes and coronary heart disease, which were also significantly higher in the severe AD group.

Data also showed that hypertension (OR = 1.61; 95% CI, 1.35-1.93) and diabetes (OR = 1.64; 95% CI, 1.27-2.12) were potential aggravating factors for AD.

One or more aggravating factors were reported by 1,953 (11.6%) participants. For example, AD severity was significantly associated with seasonal changes. Participants reported summer as a seasonal risk factor (OR = 1.23; 95% CI, 1.04-1.46).

Aggravating factors also included food, with participants showing significant AD severity associated with fish and shellfish (OR = 1.74; 95% CI, 1.35-1.98), lamb and beef (OR = 2.01; 95% CI, 1.59-2.56), chili peppers (OR = 1.52; 95% CI, 1.19-1.95) and alcohol (OR = 1.83; 95% CI, 1.36-2.48).

Age was found to be a significant association with AD severity and food. Fish and shellfish showed an association in patients aged 2 years and younger (OR = 1.5; 95% CI, 1.05-2.15) and aged 18 to 59 years (OR = 2.02; 95% CI, 1.44-2.83).

Lamb and beef were associated with AD severity in participants aged 2 years or younger (OR = 1.87; 95% CI: 1.19-2.96) and aged 18 to 59 years (OR = 3.65; 95% CI, 2.42-5.50). Chili peppers (OR = 2.03; 95% CI, 1.38-2.99) and alcohol (OR = 2.24; 95% CI, 1.47-3.42) only showed significant association with AD severity in participants aged 18 to 59 years.

Environmental factors were also found to be associated with AD severity. Sunlight (OR = 1.79; 95% CI, 1.42-2.25), humidity (OR = 1.61; 95% CI, 1.23-2.11), sweat (OR = 1.27; 95% CI, 1.08-1.48), showering (OR = 1.63; 95% CI, 1.26-2.11), skin friction (OR = 1.84; 95% CI, 1.37-2.46), dust (OR = 1.55; 95% CI, 1.24-1.92) and pollen (OR = 2.15; 95% CI, 1.54-3) all showed significant effect.

Significant psychological aggravating factors included stress (OR = 1.99; 95% CI, 1.59-2.5), emotional problems (OR = 1.8; 95% CI, 1.44-2.26), and sleep disorders (OR = 1.89; 95% CI, 1.49-2.41).

All questionnaire scores increased along the severity of each participant’s AD, with mean scores significantly higher in participants with severe vs. moderate and mild AD.

Higher proportions of moderate (10.66%) and severe (5.5%) participants reported more sleep disturbances than mild participants (28.39%). Severe AD participants reported a higher proportion of 7 days of sleep disturbances per week (46.47%) than mild (15.13%) or moderate (22.04%) participants.

Collected data showed that top therapies were topical glucocorticoids (32.26%), oral antihistamines (28.66%), moisturizers (19.58%), topical calcineurin inhibitors (5.99%), glycyrrhizin (5.82%) and dupilumab (Dupixent; Regeneron, Sanofi; 5.8%)

Researchers noted that the study results suggest that AD is poorly managed in all age groups among the participants in China with variations in AD severity across different geographic groups. Their findings also suggest that infants with greater AD severity showed higher likelihoods of developing allergic rhinitis and food allergies compared with other comorbidities. They concluded that in order to better manage AD, more attention should be given to nonatopic comorbidities in AD-specific interventions.