Itching is an immense stress factor

Numerous studies show that moderate or severe atopic dermatitis, if inadequately controlled symptomatically, results in a significant “burden of disease” and can have a negative impact on the lives of patients and their social environment. Quality of life is often significantly impaired, with the itch-scratch cycle being particularly distressing for sufferers. For many patients, therefore, itch relief is an overriding treatment goal.

In Europe, approximately 4.4% of adults and up to 18.6% of children and adolescents suffer from atopic dermatitis, with 20% of all cases being moderate to severe forms [1]. These patients have a significantly higher burden of disease compared with those with mild courses [1]. Several studies have shown that the itch-scratch cycle is not only unpleasant and debilitating per se, but leads to sleep disturbances and stigmatization. These factors result in psychosocial problems that accumulate over time and prevent patients from reaching their full potential. Inadequately controlled symptoms can thus lead to a vicious circle with negative effects at various levels.

Lack of symptom control is associated with high burden of disease

Several studies indicate that atopic dermatitis is associated with a similar or higher burden of disease as diabetes, asthma, and psoriasis [1,3]. In a large-scale Germany-wide study, one-third of over 1600 adult atopic dermatitis patients reported suffering from itch-related insomnia [3]. Moderate to severe atopic dermatitis is more common in families with a history of atopic diseases [4,5]. More than one in five atopic dermatitis patients also suffer from asthma, and the risk of allergic rhinitis and food allergies is massively increased [6]. Particularly in patients with severe atopic dermatitis, the lifetime prevalence of asthma and hay fever and the 1-year prevalence of food allergy are above average [23]. In epidemiologic studies, asthma affected more than half of adults with severe neurodermatitis courses [23]. In addition, patients may also suffer from non-atopic comorbidities such as depression, anxiety, attention deficit hyperactivity disorder, and other skin disorders (e.g., contact dermatitis, hand eczema, folliculitis) and skin infections [7–10]. While mild atopic dermatitis can be adequately controlled by means of basic care, avoidance of trigger factors and topical preparations, patients with moderate or severe courses require a more comprehensive treatment strategy to achieve symptom control, with modern highly effective systemic therapeutics now available [11].

Itch relief as the most important treatment goal for patients

The main symptom of moderate to severe atopic dermatitis is persistent itching. Repeated scratching of the affected areas can aggravate the inflammatory, bleeding, and painful skin lesions [12]. This often has a negative impact on sleep patterns and overall psychological and social well-being [13,14]. The itch-scratch circuit is considered the factor that most affects the quality of life of patients and their families [15,16]. The consequences of the agonizing itch range from sleep disturbances, to emotional and behavioral problems, to difficulties in daily personal and professional life [17]. These effects are particularly severe in patients with severe atopic dermatitis [18] (Fig. 1). In a cross-sectional U.S. study published in 2019 with a total of over 2800 adult study participants, atopic dermatitis patients had higher mean scores on the Hospital Anxiety and Depression Scale (HADS) subscales of depression (HADS-D) and anxiety (HADS-A) compared to a healthy control group, with moderate and moderately severe atopic dermatitis positively correlated with higher HADS-A and HADS-D scores. A 2017 population-based survey study involving more than 34,000 Swedish adults clearly indicated that patients with atopic dermatitis are at increased risk of depression, and the magnitude of the risk increase correlated with the severity of atopic dermatitis. Thus, the adjusted risk ratio (aRR) for mild atopic dermatitis was 1.78 (95% CI; 1.50-2.12), whereas for severe atopic dermatitis, an aRR of 6.22 (95% CI; 4.60-8.42) was documented [15].

In order to be able to differentiate the individual burden of disease and the impact on quality of life, the consideration of the patient’s perspective and psychosocial aspects is central [1]. In a German study involving 91 dermatological practices and outpatient clinics, the personal treatment goals of more than 7500 patients were collected. The goal most frequently mentioned by patients was “not to have itching” (96.0%) followed by “rapid improvement of skin condition” (87.8%) (Fig.  2) [19]. This highlights the distress caused by excruciating pruritus and the importance of itch-relieving treatment options.

Effective therapy reduces disease burden

Psychological concomitants such as anxiety, depression, and social isolation can accumulate over a long period of time in people with atopic dermatitis and prevent patients from reaching their full potential [8]. Moderate to severe atopic dermatitis can significantly affect patients’ ability to work and lead to absences due to illness [13]. Studies have shown that the impact on work performance accounts for most of the economic burden caused by moderate to severe atopic dermatitis [14,22]. In addition, feelings of shame, bullying and teasing often push those affected into social isolation and interfere with everyday life [20]. Effective symptom relief can result in substantial improvement in patients’ quality of life and performance. In view of the multidimensional psychosocial effects of atopic dermatitis, it is important to develop individual therapy plans with reference to the guideline-based stepwise treatment scheme. How atopic dermatitis affects the patient’s quality of life, and which coping strategies are chosen, vary from individual to individual [21]. In order to be able to implement the most sustainable “disease management” possible, the patient’s treatment goals and various psychosocial factors should also be taken into account when drawing up the treatment plan.

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DERMATOLOGIE PRAXIS 2022; 32(5): 32-34