Atopic eczema has an association with increased risk of new-onset depression and anxiety, but the nature of this association is still unclear. Atopic eczema (AE) is a common relapsing inflammatory skin disorder in both children and adults. AE causes intense itchiness and discomfort, heavily affecting the quality of life of the individual. These individuals may be more likely to suffer from anxiety and depression due to the appearance of the skin caused by chronic itchiness and discomfort, in addition to social stigmas. Insight into this temporal relationship of AE and anxiety could help guide the clinical approach and recommendations for management.
Recent AE guidelines from the European Academy of Dermatology and Venereology do comment on the psychological and emotional factors influencing the clinical course of AE, but a study done by Schonmann and colleagues suggests that anxiety and depression should be explicitly addressed in these guidelines. Because AE is so common, if there is risk of increased new-onset anxiety or depression, it would suggest three things: 1) a major population impact, 2) potential for targeted mental health screening in AE individuals and, 3) the possibility of mental health modification through improved AE control (Schonmann et al., 2020). Schonmann and colleagues found that AE was associated with a 14% increase of newly diagnosed depression and a 17% increase in anxiety diagnosis. The risk of depression increased as the severity of AE increased, which provides strong evidence for dose-response association, therefore suggesting a causal mechanism for the association. With these findings, physicians may be able to improve AE control by facilitating more consistent treatments or through anti-inflammatory effects of antidepressants (Schonmann et al., 2020).
Mental illness is under-diagnosed in people with skin or other chronic diseases (Schonmann et al., 2020), and while this study mainly focuses in the UK, their findings can be applied to the guidelines set by the American Academy of Dermatology (AAD) or any other relevant settings. The AAD guidelines also briefly mention the mental health associations to AE such as depression, but do not comment on the long term mental health implications (Atopic dermatitis clinical guideline). Overall, the results show an increased risk of new-onset depression and anxiety, which should be considered in the recommendations for management of AE. This could improve current guidelines and limit new-onset mental illness diagnosis.
Atopic dermatitis clinical guideline. American Academy of Dermatology. (n.d.). https://www.aad.org/member/clinical-quality/guidelines/atopic-dermatitis.
Schonmann, Y., Mansfield, K. E., Hayes, J. F., Abuabara, K., Roberts, A., Smeeth, L., & Langan, S. M. (2020). Atopic Eczema in Adulthood and Risk of Depression and Anxiety: A Population-Based Cohort Study. The journal of allergy and clinical immunology. In practice, 8(1), 248–257.e16. https://doi.org/10.1016/j.jaip.2019.08.030
This was a super interesting read, Kayla! I enjoyed how you linked a dermatologic condition (atopic eczema) and anxiety as it was a different viewpoint from just addressing either issue. I just had a few further questions regarding some of this research that I thought could be potentially interesting to answer. You mentioned in your blog post that the AAD guidelines do not comment on the long-term mental health implications. If you were to hypothesize what some of these long-term effects would be, what would be your best guesses? In addition, I was kind of confused with the articles view on using antidepressants and how these can be used in an anti-inflammatory way. This note has led me to a larger interest in the other pharmaceutical effects in antidepressants and other long-term medications. I personally investigated other pharmaceutical uses for antidepressants. With my original search, I had found that antidepressants can be used to treat major depression, anxiety, PTSD and OCD. One other interesting use for antidepressants that I found was treatment of bed wetting with antidepressants. The first-round treatment for bedwetting is particularly an antidiuretic hormone called desmopressin. The second-round treatment for bedwetting that has been approved is by treatment with tricyclic antidepressants. This treatment has actually been approved and occasionally utilized since the 1960’s, which I thought was also interesting. In a study published in 1968, an older article, in about 30% of cases, antidepressants were found to significantly decrease incidences of bedwetting in children. However, using antidepressants for this is not generally recommended and are sometimes avoided due to the hormonal changes and differences in children (Milner et al., 1968).
ReplyDeleteTherefore, I leave with one question, what do you think are the benefits of using a different drug treatment for specific patients? Do you know any cases where drugs have been used to treat for non-FDA approved treatments?
Milner, G., & Hills, N. F. (1968). A double-blind assessment of antidepressants in the treatment of 212 enuretic patients. Medical Journal of Australia.
Danielle, thank you for your insight! I would guess that some of the long-term effects could be a decrease in social activity and potential social anxiety as a result. There is a lot of social stigma and pressures around skin and the appearance of skin. Given the characteristics of eczema and how uncomfortable it can be, an individual may want to avoid any social interactions because of embarrassment or discrimination they may face. I personally struggle with eczema and it gets very frustrating when I am constantly uncomfortable. Being out socially sometimes makes me very anxious because of how my skin looks. Sometimes not being able to have good control of the condition, let alone the pain and discomfort can be something that keeps me from wanting to interact with others. The researchers believe that an individual who has atopic eczema and is diagnosed with depression, antidepressants that have an anti-histamine property to them are able to decrease inflammation. A literature review found that for chronic dermatological disorders such as atopic eczema or psoriasis TCAs and mirtazapine have relevance because of their anti-histamine properties. They also found that a newer antidepressant, bupropion, a noradrenaline and dopamine reuptake inhibitor reduces psoriasis lesions and atopic eczema (Eskeland et al., 2017). While there have been a lot of evidence of anti-inflammatory properties in antidepressants, the clinical implications of the properties are still unknown and there needs to be more research. To answer your question, think it's beneficial to use different drug treatments for specific patients who may have the condition more severe than another person. I also think it's beneficial because a drug that may work for one person, may not work for another so having those different options would be better than not. I think there would have to be careful consideration though when it does come to children because of the possibility of hormonal changes or developmental disruptions. I don't know of any cases where drugs have been used relating to eczema specifically, that is something I'll have to look into more!
DeleteEskeland, S., Halvorsen, J., & Tanum, L. (2017). Antidepressants have anti-inflammatory effects that may be relevant to dermatology: A systematic review. Acta Dermato Venereologica, 97(8), 897–905. https://doi.org/10.2340/00015555-2702
Hey Kayla,
ReplyDeleteThis was a really interesting post. I never thought about a skin disorder having an impact on mental health, but after reading your post it makes total sense. I did a little more research and found some more interesting implications of eczema. A study done on a sample of 5,265 Dutch children found that those who identified with any of the predetermined eczema phenotypes had more somatic symptoms (ex. dizziness, headaches) and attention problems at school. Researchers also concluded that eczema very modestly affects emotional and behavioral problems. I thought these findings were very interesting. I think more research needs to be done on this topic to better understand the experience of those who live with eczema. Thanks for the info!
Maddie, after finding this article it did make me think more about other diseases and the way mental health may be affected. That is also a really interesting study that you found! It's definitely interesting that eczema can not only be associated to anxiety and depression, but it can also affect their emotions and behavior. I definitely agree that there should be more research done to have a better understanding and potentially an improved treatment protocol.
DeleteHere is the citation of the study I found!
ReplyDeleteEczema and emotional and behavioural problems in childhood. (2020). British Journal of Dermatology, 183(2), e40. https://doi-org.dml.regis.edu/10.1111/bjd.19274
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ReplyDeleteKayla, what an informative read! As someone who has eczema, I never thought to look into the psychological aspect of having this skin disorder, but it does make sense. Everytime I go out I feel like I’m being judged for how my skin looks, people avoid me and look at me like I have some type of skin disease. It definitely takes a hit to my self-confidence, it also does not help that we live in such a dry state and winters seem to make it worse. I wanted to try to answer a question Danielle had in her comment about hypothesizing what long-term mental health implications have on people with this disorder. Some say children will outgrow eczema, but epidemiological studies have shown that it is a lifelong disorder, it may get milder but it never truly goes away (Ghio et al., 2020). I think for those who are living with eczema they learn to live around their disorder and not allow it to dictate their life. If there is a bigger awareness of the impact of around the message that young children will ‘grow out of’ eczema and informing patients with high-quality information may help them learn to manage expectations and find supportive adaptations to specific treatment regimens early on (Ghio et al., 2020). A greater focus on self-care for a long-term condition in young people may be beneficial in coping with skin and other chronic disorders as they grow older. If I had supportive measures when I was younger, maybe I would not be as self-conscious and anxious when meeting people as I am now. I agree that mental illness is underdiagnosed, but could it be that those who have eczema and other skin-related disorders do not want to come out to their attending healthcare professionals as having a “mental disorder,” since there is still such a stigma around having depression and anxiety? What do you think should be done about mental health education while diagnosing skin disorders; should it be talked about with the patient at a young age allowing them their own autonomy to learn more about the impact of this disorder, or should they wait until they are 18 and out of their parents jurisdiction to take charge of their mental health? Would 18 be too late to know about the impact of mental health on lifestyle?
ReplyDeleteGhio, D., Muller, I., Greenwell, K., Roberts, A., McNiven, A., Langan, S. M., & Santer, M. (2020). ‘It's like the bad guy in a movie who just doesn't die’: a qualitative exploration of young people's adaptation to eczema and implications for self‐care. British Journal of Dermatology, 182(1), 112-118.
Van, thank you for sharing your experience. I can relate to how you feel. I had eczema when I was born but it "went away" and just recently started to appear again, but more severe. It gets very hard some days to in public being uncomfortable and self-conscious. I also didn't really think about looking into psychological aspects of having eczema until I realized how much it affected my self-confidence and my mood. You make a really great point about finding ways to navigate living with the condition. I think if more people were to be aware that the condition never truly goes away, there could be improved treatment protocols that would be more consistent to better control it. You also bring up a really valid point about not wanting to tell the provider about having a mental disorder. It is a big possibility because of how taboo the topic of mental health is. I personally have some hesitancy to tell my provider because of that stigma. I think having these conversations with the patient at a young age with the parent present would be beneficial. Being able to understand what they may experience could also allow the individual to feel more comfortable talking to their provider and/or their parents about having anxiety or depression. I think that it is also important to promote mental health at a younger age and allow for that freedom to talk about what they experience. These were really great questions and a thoughtful response!
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