Beyond the Skin: Addressing the Hidden Burden of Atopic Dermatitis

In this episode of Topical Conversations, Nicholas Brownstone, MD, sits down with Dawn Merritt, DO, to discuss the often-overlooked impact of atopic dermatitis (AD). While dermatologists may see a rash that appears mild, for many patients the disease affects far more than the skin, touching sleep, mental health, cognitive function, and overall quality of life across all age groups.

Pediatric burden

Dr Merritt emphasizes that pediatric patients and their families face a unique set of challenges. Children with AD often require multiple prescriptions per year, and caregivers may spend more than 10 hours weekly managing symptoms. This burden extends beyond the patient, commonly affecting parents’ time, energy, and mental health.

The itch burden and mental health

Pruritus is central to the disease burden in AD. Studies show patients with itch experience worse quality of life than those with chronic conditions like heart failure or stroke. Sleep disruption from itch can contribute to depression, anxiety, and even suicidal ideation. Dr Merritt notes that over 85% of patients with moderate-to-severe AD report at least itch or sleep disturbance as a symptom.

Impact on school performance

Children with AD may miss school due to rash, infection, or poor sleep. Even when present, they often struggle to concentrate (presenteeism), which can affect academic performance and self-confidence.

Asking the right questions

Both speakers stress the importance of asking beyond “How are you doing?” to uncover a patient’s full burden of AD. Specific questions about sleep, school, itch severity, and mental health allow patients and families to share concerns not visible on exam. Simple tools such as the Atopic Dermatitis Control Test or the PHQ-2 depression screen can help integrate formalized assessments into a busy clinic.

Systemic therapies and emerging data

For patients with significant quality-of-life impairment, Dr Brownstone recommends considering systemic therapy and referral to mental health support. Emerging data highlight that systemic biologics, such as dupilumab, may not only control skin symptoms but may also potentially improve growth outcomes and reduce ADHD medication needs in pediatric patients.  

A new therapeutic landscape for pediatric patients

Systemic options for AD have been expanding rapidly. Dupilumab is approved for patients as young as 6 months, while biologics such as lebrikizumab, nemolizumab, and tralokinumab are available for patients aged 12 and older. Compared to the limited options of the past, Dr Brownstone describes this as a “golden age” for pediatric AD management.

Addressing comorbidities and empowering families

Drs Brownstone and Merritt conclude their discussion by emphasizing that effective care includes addressing comorbidities such as sleep disturbance and depression. Dr Merritt also uses simple, relatable tools, like asking children to grade their AD with a letter grade, which helps track disease burden across visits. Both recommend connecting families to resources such as the National Eczema Association to provide education and empowerment.

Key takeaways

• AD can impact far more than the skin, affecting sleep, mental health, school performance, and family well-being
• Pruritus is a key driver of quality-of-life impairment and may be linked to higher rates of depression and suicidality
• Asking specific, pointed questions or using simple screening tools can help clinicians uncover the true burden of disease for their patients
• Systemic therapies like dupilumab are transforming pediatric AD care and may offer benefits beyond skin clearance
• For patients with even mild-appearing rashes but severe life impact, systemic agents or mental health referrals should be considered
• Providing families with trusted resources, such as the National Eczema Association, can help foster education, empowerment, and adherence