VIDEO: Addressing comorbidities in patients with atopic dermatitis

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Common comorbidities for anybody who has atopic dermatitis and particularly as the age goes up are the allergic comorbidities. We're talking about hay fever or allergic rhinitis. We're talking about asthma, food allergies — and I'm saying true food allergies, not the fact that the prick test or a blood test was positive because that's so common in atopic dermatitis but doesn't mean that they're allergic to food. We might also be considering other comorbidities like eosinophilic esophagitis or even urticaria, which can contribute to the risks. Now, when we think about these other agents in terms of comorbidities, we need to recognize that they can exacerbate the burden of atopic dermatitis.

Of course somebody who has urticaria is going to be scratching the skin and that's not going to help with the atopic dermatitis and yet may not be responding to the topical steroid that you might be using, for example for the atopic dermatitis. Patients with allergic rhinitis, for example, notoriously can have sleep issues. And you might find that you're using an agent that's been highly successful for the atopic dermatitis and yet the patient is still tired because the allergic rhinitis is keeping the patient up at night. And then there are the comorbidities that are neuropsychological. We have to be thinking about that increased risk of attention deficit with or without hyperactivity. And there has been shown to be an increased risk.

There are always the issues with school because if you're sitting there and you can't pay attention because you're distracted by your itch and you're scratching all the time, and that's a different story. That's a direct sequela of the atopic dermatitis as opposed to a comorbidity. Psychiatric issues, anxiety, depression occur more frequently with atopic dermatitis. Even suicidal ideation particularly with those who have moderate to severe disease. So [it’s] very important to monitor this to track it as we're engaging in treatment and that highly successful treatment and make sure that those comorbidities turn around. Now, comorbidities like infections or the contact dermatitis that I mentioned before are ones that we should be paying attention to at every visit. They are comorbidities that are certainly easily treatable if you identify them and jump in with the appropriate management. There are other comorbidities that have been associated. I think one of the considerations is in a child who struggles with asthma, for example, and atopic dermatitis that might direct what you're going to use because dupilumab (Dupixent; Sanofi Genzyme/Regeneron) has been shown to be quite helpful, for example, for asthma as well as atopic dermatitis. Whereas some of the other biologics that are out or coming out have not had the benefit of being able to show a positive effect. So that can also skew how one might make a decision. Now for those children, for example, with severe alopecia areata, which interestingly occurs more often with atopic dermatitis. So, one could think about that as another comorbidity and that's been shown to be true.

With alopecia areata, maybe that is a reason to consider using a JAK inhibitor instead of dupilumab or a biologic first line. Although there's been some very interesting data with long-term continuation on the dupilumab and hair regrowth in alopecia areata. More to learn on that in the future. So, there are some reasons why we might consider one vs. another when we're choosing a direction in systemic therapy that relates to the comorbidities. But most important is to talk with the patient, talk with the family, and find out if there are comorbidities and make sure that the child is being treated for them which may require referral to an expert, for example, in allergy or sleep or psychiatry.