“The impact of atopic dermatitis (AD) on HRQOL is dynamic,” explains Jonathan Silverberg, MD, PhD, MPH. “Much of the negative HRQOL impact of AD is related to the severity of disease signs and symptoms. As such, patients with different severities and longitudinal courses of AD may consequently experience different impacts and courses of HRQOL. In addition, many patients with AD are unable to perform activities of daily living routinely and need to avoid tasks that might trigger their disease. This might lead to a persistent HRQOL impact even when the symptoms are milder. However, most tools used to assess HRQOL are cross-sectional, and few studies have examined the longitudinal course of HRQOL in patients with AD.”
For a paper published in Clinical and Experimental Dermatology, Dr. Silverberg and colleagues sought to assess predictors, longitudinal course, and phenotypes of HRQOL in adult patients with AD. They conducted a prospective, dermatology practice-based study of 955 patients who were evaluated at baseline and approximately 6, 12, 18, and 24 months. HRQOL was measured using the PROMIS Global Health (PGH) 10-item short-form. AD severity and impact was evaluated by patient-reported global AD severity, Patient-Oriented Eczema Measure (POEM), Eczema Area and Severity Index (EASI), objective-SCORing AD (SCORAD), Investigator’s Global Assessment (IGA), Numerical Rating Scale (NRS) average and worst-itch, PROMIS sleep-related impairment, and Patient Health Questionnaire (PHQ)-9.
AD Severity Strongest Predictor of HRQOL Impact
The study team found that at baseline, overall physical and mental health was inversely related to the severity of itch and AD lesions. “In addition, AD severity was the strongest predictor of more persistent HRQOL impact,” Dr. Silverberg says. “Most patients had persistent or fluctuating HRQOL impact over time, indicating significant unmet needs with current standard of care therapy for AD.”
Interestingly, Dr. Silverberg adds, many patients with major HRQOL impact did not have severe lesion scores. “That is, the lesions may appear mild to a dermatologist or other physician, but patients still suffer from more severe symptoms that negatively impact their QOL,” he says.” These results underscore the importance of clinicians assessing the symptoms and QOL impact from AD in addition to skin examinations. Moreover, many patients had persistent impacts on mental health and physical health even after their disease severity improved. This suggests that some patients have an ongoing need to avoid activities that could trigger their disease even when they are having a ‘good day.’ Moreover, some patients have a progressive disease course that may permanently impact patients’ mental and physical health.”
Racial, Ethnic & Healthcare Disparities Found
The researchers also found six different classes, or patterns, of HRQOL, which were associated with different constellations of AD sign and symptom severity. “We discovered that patients with the worst HRQOL impact were more likely to be non-White, Hispanic, and have public insurance, even after controlling for AD severity,” Dr. Silverberg says. “This indicates there are racial, ethnic, and healthcare disparities with respect to HRQOL in AD (Table).”
Dr. Silverberg and colleagues noted important takeaways from their research. “First, it is imperative that clinicians assess the symptoms and QOL impact of AD, in addition to lesion severity,” he says. “Second, they should incorporate these tools into treatment decision-making. That is, severe itch or skin pain should carry just as much influence to determine when a patient is having an inadequate response to therapy and needs to be ‘stepped up’ to something stronger. Third, validated and standardized tools provide rich information about the burden of disease and are feasible for use in clinical practice. We recommend that dermatologists incorporate these tools into practice to improve quality of care.”
Finally, the researchers note there are several ongoing follow-up studies on this topic. “One particularly key area of inquiry is to determine which patients will have a progressive course of AD and have persistent mental and physical health problems despite improvement of their signs and symptoms,” Dr. Silverberg says.