Atopic dermatitis does not exist in a bubble, often coexisting with asthma, immune-mediated disorders, and even depression. A new American Academy of Dermatology (AAD) guideline describes available evidence on comorbidities associated with atopic dermatitis in adults and provides recommendations on how clinicians, including nurse practitioners and PAs, can support health in patients with atopic dermatitis and comorbid disorders. The guideline was published in the Journal of the American Academy of Dermatology.

To develop the guideline statement, an AAD multidisciplinary work group reviewed the medical literature that discussed associations between atopic dermatitis and selected comorbid conditions. In the review, the AAD guideline committee identified several atopic and allergic conditions associated with atopic dermatitis:

  • Asthma: The guideline authors reported that their meta-analysis of research on asthma in patients with atopic dermatitis found that the pooled prevalence of asthma in adults with atopic dermatitis is 24.8%. The guideline authors noted, however, that there is “substantial heterogeneity” across studies. Compared with the general population, the guidelines authors wrote, adults with atopic dermatitis are 3 times as likely to have an asthma diagnosis. In addition, the guideline committee wrote that severe atopic dermatitis may have a stronger relationship with asthma compared with mild or moderate atopic dermatitis. The guideline authors also explained that the “atopic march” concept as an explanation for asthma and atopic dermatitis association is unproven.
  • Food allergy: The pooled prevalence of food allergy in adults with atopic dermatitis is 11%, but the guideline authors stated that this prevalence rate is limited by substantial heterogeneity across available studies. Similar to asthma, the guideline panel noted that higher levels of atopic dermatitis severity related to higher rates of food allergy, with the odds of food allergy increasing from mild (risk ratio [RR], 1.48; 95% CI, 0.89-2.07), to moderate (RR, 2.40; 95% CI, 1.54-3.27), to severe (RR, 8.49; 95% CI, 5.44-11.54) AD, compared with the general population.
  • Allergic rhinitis, conjunctivitis, and eosinophilic esophagitis: According to the guideline, allergic rhinitis is a common comorbidity in patients with atopic dermatitis and is also a component of some diagnostic criteria for the dermatologic condition. In contrast to allergic rhinitis, the guideline panel wrote that there was little evidence to support an association between atopic dermatitis and eosinophilic esophagitis as well as allergic conjunctivitis.

Also, the guideline authors noted that there is clear evidence of an association between immune-mediated conditions and atopic dermatitis:


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  • Alopecia areata (AA): The guideline authors cited epidemiologic data showing an association between atopic dermatitis and AA. Additionally, the guideline authors noted a belief that the presence of atopic dermatitis portends a worse prognosis for AA but stated that studies are limited to confirm this notion. The guideline committee wrote that Janus kinase inhibitors have demonstrated promise for both AA and AD, but these investigational agents had not yet been approved for either indication in the United States.
  • Urticaria: The guideline authors also cited research showing strong associations between chronic urticaria and atopic dermatitis. According to the guideline statement, pruritus associated with chronic urticaria may potentiate the itch-scratch cycle in patients with atopic dermatitis, resulting in worsened dermatitis.

Some evidence has also supported an association between mental health conditions and substance abuse and atopic dermatitis, according to the guideline panel:

  • Depression, anxiety, and self-harm: The guideline authors cited some studies showing that adults with atopic dermatitis tend to report more symptoms of anxiety and depression and have higher diagnoses of depressive or anxiety disorders than the general population. The psychosocial burden of atopic dermatitis may be a possible explanation for this association.
  • Substance abuse: Very little evidence has supported an association between atopic dermatitis and cigarette smoking or alcohol use, the guideline authors stated. However, the guideline committee cited a study that found that alcohol abuse was more common in adults with atopic dermatitis than in the general population. Additionally, the authors cited a US population-based survey that found an association between atopic dermatitis and having smoked 100 or more cigarettes and being a current smoker.
  • Attention deficit hyperactivity disorder (ADHD) and autism spectrum disorders: the guideline authors noted that they found only 1 study that identified an association between ADHD and atopic dermatitis in adults. The guideline authors also found a study that described a positive association between autism spectrum disorder and atopic dermatitis in adults, but the confidence intervals in this study “were very wide,” they wrote.

Other conditions associated with atopic dermatitis were also defined by the guideline committee’s literature review:

  • Cardiovascular diseases (CVDs): The guideline authors wrote that CVDs have also been associated with atopic dermatitis, given that systemic inflammation represents a key risk factor for heart disease. According to the authors, there is mounting epidemiologic evidence showing “small associations between atopic dermatitis and hypertension, peripheral and coronary artery disease, congestive heart failure, and acute events such as myocardial infarction and cardiovascular death” but noted that “the clinical implications of these associations are unclear.”
  • Bone health: Some research has pointed to an association between atopic dermatitis and an increased risk of osteoporosis fracture, the guideline committee added. The guideline authors explained that the chronic systemic inflammation in atopic dermatitis may result in “aberrant bone metabolism and increased bone loss.”

The guideline authors recommend individualized treatment and shared decision-making between patients with atopic dermatitis and their dermatologist and/or primary care provider (PCP). In addition to a consultation with a dermatologist, the guideline suggests patients should consult with a PCP to assess and manage comorbidities outside of dermatologic practice. These efforts should incorporate both awareness and consideration of comorbidities, the guideline panel stated. According to the authors, patients who understand the association between different comorbidities and atopic dermatitis can feel more empowered, given they better understand their disease and overall health. In turn, these patients may play a more active role in their healthcare decisions, thereby supporting quality of life and wellbeing.

Disclosure: Multiple authors declared affiliations with the pharmaceutical industry. Please refer to the original article for a full list of disclosures.

Reference

Davis DMR, Drucker AM, Alikhan A, et al. American Academy of Dermatology Guidelines: Awareness of comorbidities associated with atopic dermatitis in adultsJ Am Acad Dermatol. 2022;86(6):1335-1336.e18. doi:10.1016/j.jaad.2022.01.009

This article originally appeared on Dermatology Advisor