What is the primary driver of reduced quality of life in patients with atopic dermatitis?

Pruritus is the Primary Driver of Reduced Quality of Life in Atopic Dermatitis

Pruritus (itching) is the primary driver of reduced quality of life in patients with atopic dermatitis, leading to sleep disturbance, emotional distress, and impaired daily functioning. 1 The intense itching characteristic of atopic dermatitis creates a vicious cycle of scratching, skin damage, inflammation, and worsened symptoms that significantly impacts patients' overall well-being.

Impact of Pruritus on Quality of Life

Sleep Disruption

• Sleep disturbance is extremely common, affecting up to 60% of children with atopic dermatitis and increasing to 83% during disease exacerbations 1
• Even when in clinical remission, individuals with atopic dermatitis demonstrate more sleep disturbance than healthy individuals 1
• Sleep disruption affects not only the patient but also family members who may be awakened by the patient's scratching and discomfort 1

Emotional and Psychological Impact

• Depression has been documented in both adolescents and adults with atopic dermatitis 1
• There is a suggested association between atopic dermatitis and behavioral disorders such as attention deficit hyperactivity disorder (ADHD), particularly in children 1
• The relationship between sleep disturbance from pruritus and ADHD-like behaviors requires further investigation 1

Daily Functioning

• Pruritus leads to impedance of daily activities, including negative effects on work or school performance 1
• Ratings of itch intensity significantly and inversely correlate with quality of life measures 1
• When parents are asked about the effects of their child's disease, difficulties due to itching and resultant scratching are typically the first to be mentioned 1

Assessment of Pruritus and Quality of Life

Measuring Impact

• More than 20 different AD-specific, dermatology-specific, and generic scales exist to measure quality of life and psychological outcomes in patients with atopic dermatitis 1
• The most commonly used scales include:
  • Children's Dermatology Life Quality Index (CDLQI)
  • Dermatitis Family Impact (DFI)
  • Dermatology Life Quality Index (DLQI)
  • Infant's Dermatology Life Quality Index 1

Holistic Assessment

• Assessment of the impact of atopic dermatitis must include consideration of both disease severity and quality of life 1
• Even if the extent of disease is small (e.g., just the face, hands, or genital area), the impact on the individual patient may still be severe 1
• Patient-reported outcomes are critical for evaluating the true burden of disease 1

Systemic Therapy Considerations

When to Consider Systemic Therapy

• For patients with severe pruritus that significantly impacts quality of life despite optimized topical therapy, systemic therapy may be necessary 1
• The decision to start systemic medication should include assessment of:
  • Severity of pruritus and its impact on sleep
  • Quality of life impairment
  • Individual's general health status
  • Psychological needs 1

Before Initiating Systemic Therapy

• Ensure optimal topical therapy has been attempted
• Provide adequate patient/caregiver education
• Treat coexistent infections
• Consider phototherapy as an option 1

Management Strategies for Pruritus

Topical Therapies

• Proactive maintenance therapy is recommended for patients with frequent relapses or chronic disease 2
• Medium-potency topical corticosteroids applied 1-2 times weekly to previously affected areas can help prevent flares 2
• Topical calcineurin inhibitors (tacrolimus or pimecrolimus) applied 2-3 times weekly are preferred for sensitive areas such as the face, neck, and skin folds 2

Addressing Sleep Disturbance

• Managing nocturnal pruritus is essential for improving sleep quality 1
• Nighttime factors that can exacerbate pruritus include:
  • Cortisol nadir
  • Increased skin temperature
  • Poor barrier function
  • Increased susceptibility to infections 1

Common Pitfalls in Managing Pruritus in Atopic Dermatitis

• Overreliance on antihistamines: H1-antihistamines are not fully effective against the intractable itch in atopic dermatitis as much of the pruritus is histamine-independent 3
• Inadequate assessment of disease impact: Focusing only on visible skin lesions without considering the subjective burden of pruritus 1
• Insufficient attention to sleep disturbance: Failing to address sleep problems can lead to worsened quality of life and potentially contribute to growth issues in children 1
• Underestimating psychological impact: Not recognizing or addressing the emotional and psychological toll of chronic pruritus 1

By addressing pruritus as the primary driver of reduced quality of life in atopic dermatitis, clinicians can better focus treatment strategies to improve patient outcomes and overall well-being.