John* and Jason* are brothers who have suffered from moderately severe atopic eczema since the age of 4 years old. They are currently studying in secondary school, but instead of enjoying the full social and academic experience like their peers, the extent and chronicity of their eczema are affecting their daily quality of life and sleep. The itchy and sometimes painful symptoms of eczema affect their ability to concentrate in school and participate in their favourite co-curricular activities of basketball and track and field. The stress from preparing for their examinations also adds to the burden and aggravates their eczema. They often feel frustrated at having to adhere to various skin care routines or avoid certain physical activities they enjoy. They also feel embarrassed about rashes on visible parts of their skin.
However, John and Jason are not alone. Atopic eczema, more commonly known as eczema, is the one of the most common skin conditions with a significant disease burden (the impact of a health problem on a given population). It is increasing in prevalence and currently affects about 20 per cent of children and 10 per cent of adults in developed parts of the world, including Singapore.
Eczema has an important psychosocial impact, with numerous studies linking it with various neuropsychiatric conditions such as anxiety, depression and suicidal ideation in adults and children, as well attention deficit hyperactivity disorder (ADHD) in children.
Eczema is typically chronic in nature with intermittent flare of itchy rashes, and significantly affects work, leisure, sleep and quality of life. Therefore, it is not surprising that eczema has an important psychosocial impact, with numerous studies linking it with various neuropsychiatric conditions such as anxiety, depression and suicidal ideation in adults and children, as well attention deficit hyperactivity disorder (ADHD) in children. This could be a result of eczema’s multiple disease associations, or downstream disease complications including its consequences on sleep and psychological health. Eczema commonly occurs on visible parts of the body and can have a profound impact on the psycho-emotional development of adolescents and young adults who tend to be conscious about their physical appearance and changes.
Specifically, a combined analysis in 2018 of up to 23 international studies reported that those with atopic eczema were more than twice likely to suffer from depression or anxiety among adults. Among children, those with eczema were 1.27 times more likely to have depression. Of note, the study reported a positive association between atopic eczema in adults and adolescents and suicidal ideation — the risks can go up to more than four times.
Various population studies have also reported an association between atopic eczema and ADHD. Those with atopic eczema have 43 per cent increased risk to be diagnosed with ADHD. Eczema occurring within the first year of life was also found to be associated with development of ADHD symptoms later in childhood. Sleeping problems due to eczema have been suggested to play an important role for the association.
Eczema on the back of knees (Photo: National Skin Centre)
Locally, we evaluated the psychosocial impact of skin diseases in a general population between 2016 and 2018. More than 1,500 adult participants (aged 21 years and above) from central Singapore were interviewed about their dermatological history and measures were used to measure their depressive symptoms, social isolation, loneliness and quality of life. Of a list of 13 skin diseases, the most common among the participants was eczema at 8.8 per cent. Participants with skin diseases were more likely to experience depressive symptoms, social isolation, loneliness and lower quality of life. Unemployed, single and elderly patients ran a higher risk of developing depressive symptoms.
Besides the psychological impact, eczema also inflicts a huge economic burden on patients and imposes substantial direct and indirect costs with a large proportion arising from out-of-pocket expenses (37 per cent according to US statistics). It has been estimated that atopic eczema (also known as atopic dermatitis or AD) costs over USD$5 billion annually in the United States of America. In Singapore, the average annual cost per child with AD was estimated at USD$7,943 in 2017. Besides excess health care expenditure, eczema also imposes costs in the form of lost productivity and foregone economic growth as a result of lost work days, lower productivity at work and morbidities in terms of itch and loss of sleep. This often leads to a continual vicious spiraling cycle between psychological stress and economic burden.
Fortunately for John and Jason, growing up with this chronic skin condition together has allowed them to encourage each other throughout their long patient journey. Having this brotherly emotional support goes a long way to help them cope with their rigorous skin care routines and avoid triggers. But for many similarly struggling adolescent patients, the social, peer and school support becomes very important. Such things should not be left to chance.
Hence, it is important for healthcare physicians as well as parents and caregivers to be vigilant for psychiatric symptoms in both children and adult patients with atopic dermatitis. Adequate emphasis should be placed on managing these psychiatric co-morbidities to reduce the overall burden of skin disease. Specific interventions could include monitoring patients for mood-related changes and implementing early psychosocial interventions. Counsellors and psychologists could be included as part of a holistic eczema care model. Recent clinical trials have also illustrated that if the eczema condition is improved, the burden of psychiatric comorbidities can be reduced. This further highlights the importance of timely intervention in this common skin condition.
*Names have been changed for privacy.
Yew Yik Weng is a Consultant Dermatologist at the National Skin Centre (NSC) with strong clinical and research interests in atopic eczema. He is also currently the consultant in charge of Eczema Clinic and deputy head of Research Division in NSC. He is active in various types of research in atopic eczema and his main area of interests is to understand the disease prevalence, co-morbidities and burden of atopic eczema in Singapore.