Healing both body and mind in atopic dermatitis

Sasha D. Jaquez, PhD

Patients often suffer with much more than the skin manifestation of atopic dermatitis (AD), or eczema. Children with AD who present to pediatricians also may be more likely to experience decreased self-esteem, anxiety, bullying, and more, says Sasha D. Jaquez, PhD, a pediatric psychologist at Dell Children’s Medical Center and assistant clinical professor of Psychiatry, Dell Medical School, University of Texas at Austin.

A tough road for kids with eczema

Researchers analyzing health status data from 92,649 noninstitutionalized children, aged 0 to 17 years, found a “striking association between mental health disorders and AD in the US pediatric population. The severity of the skin disease alters the strength of the association,” they wrote in a paper published in 2013 in the Journal of Allergy and Clinical Immunology.¹

Researchers studying psychosocial problems in adolescents with eczema found that 15.5% of teenagers with current eczema reported suicidal ideation compared with 9.1% of those without eczema.² Another finding from that study: Boys with current eczema were less likely to have had romantic relationships than those without, according to the study in the Journal of Investigative Dermatology.

In a study published in the Scandinavian Journal of Caring Sciences, researchers concluded that teasing, taunting, and bullying may represent an underappreciated source of psychologic morbidity in children and adolescents with eczema, acne, and psoriasis.³

Pediatric dermatologic disorders, including AD, impact self-esteem throughout childhood, according to a study published in the International Women’s Journal of Dermatology.⁴

“In addition to the surgical and medical management of these disorders, clinicians can also take an active role in the assessment and improvement of the psychosocial impact of these skin disorders,” those authors concluded.⁴

Pediatricians should be mindful that what they see with AD patients isn’t necessarily all that there is. They also should be cognizant about the risk for psychologic and social comorbidities, says Jaquez, who presented “Healing children one layer at a time: integration of Psychology in pediatric Dermatology,” in July during the Society for Pediatric Dermatology 44^th Annual Meeting in Austin, Texas.

“The pediatrician or dermatologist who might be the first to identify the problems but doesn’t have time to focus on this during treatment should refer to a psychologist who is trained to focus on how to get the child to be [his/her] best self despite the medical condition that they have,” Jaquez says.

Pediatric psychologists, according to Jaquez, see more than traditional outpatient mental health concerns, such as depression and anxiety.

“What sets child/adolescent psychologists and pediatric psychologists apart is that knowledge of medical conditions and working on multidisciplinary teams to address difficulties a child and family experience related to the medical condition, whether it is a diagnosable psychiatric condition or not,” Jaquez says. “This would include seeing patients for nonadherence; coping with and acceptance of a medical condition; behavior problems in younger children, which may affect their adherence; sleep problems; and anxiety and depression related to the medical condition.”

Atopic dermatitis is among the most common conditions that Jaquez sees in her practice.

“The skin is the first thing that many people see, and a lot of these kids with AD will go to great lengths to try and hide their skin. We’re in Texas where it’s 100 degrees, and I will see kids who are coming in with long-sleeved shirts and pants on because they don’t want their skin exposed for other people,” Jaquez says.

Helping kids accept their skin

Jaquez says she helps pediatric patients with AD to accept their skin. “I talk with kids all the time about how their skin is just different. It’s not that it’s bad. So, we practice how they can tell other people that,” she says. “Other children often are afraid to play with children that have AD because they’re afraid that it’s going to be contagious. So, we practice with the child and also the parent about how to educate others about what it is and that it’s not contagious.”

Jaquez also works with children and families to find things that they’re able to do and enjoy doing and encourages them to do those things. “If they’re able to accept their skin condition and that it’s going to ebb and flow in terms of flares, then we can find time that they’re able to do the things they enjoy doing,” she says.

Part of the work involves overcoming perceived barriers. If a child who likes to swim doesn’t think he or she can swim in public anymore, Jaquez will work with the child and family to find a way that the child can safely swim, without putting them in a situation where people are going to judge them for the way that their skin looks.

Atopic dermatitis may not be a life-threatening condition, but it is chronic and visible. It’s important, Jaquez says, that pediatricians don’t ignore the stress a chronic condition can put on the child and family.

“One of my biggest messages to pediatricians is to be aware that this is really difficult stuff and that it’s OK for a family to need extra support,” she says.

Jaquez recommends that pediatricians have a psychologist on their team-onsite or as a referral source. If the psychologist is onsite, pediatricians should consider introducing the psychologist to the eczema patient and family early on, before they need or access mental support. That way, the patient and family know the psychologist and might feel more comfortable accessing the provider when they do need help, she says.

When to consider referring

Pediatricians should consider referring AD patients to pediatric psychologists when pediatricians are concerned with patients’ mood, anxiety, or adherence to treatment.

“There’s a lot that patients have to do every day for their skin. I’ve talked to a number of patients where the doctor will tell me one medical regimen and I’ll check in with the family and they have heard it in a different way. Sometimes it’s just a matter of getting everybody on the same page and making sure they understand what they’re supposed to be doing,” Jaquez says. “I think if pediatricians are feeling frustrated with patients, that’s also a good time to make a referral because that means something is going on-even if they’re not able to pinpoint what that is.”

It’s important to keep in mind that parents might need psychologic support, too.

Researchers reported in a paper published in 2016 that AD in a child may lead to exhaustion, emotional distress, and depressive symptoms in parents.⁵ Identifying children with AD and their parents who need psychologic help may help to reduce emotional problems in these children and families, they wrote.

Helping to destigmatize mental health

A big takeaway for pediatricians is that they should help to destigmatize mental health by helping families understand that AD and other diseases are stressful, and that just because there’s a referral to Psychology doesn’t mean that there’s a larger concern about mental health. Rather, they’re simply in a stressful situation, so it’s OK to have Psychology involved.

“Families fear what it means when they’re getting a referral to Psychology and can be very resistant to that. It helps when pediatricians talk about Psychology as part of the team versus ‘You’re getting a referral to Psychology,’ which often can have negative connotations,” Jaquez says. “Working together as a team we’re kind of able to peel away their layers and work toward healing the whole person.”

References:

1. Yaghmaie P, Koudelka CW, Simpson EL. Mental health comorbidity in patients with atopic dermatitis. J Allergy Clin Immunol. 2013;131(2):428-433.

2. Halvorsen JA, Lien L, Dalgard F, Bjertness E, Stern RS. Suicidal ideation, mental health problems, and social function in adolescents with eczema: a population-based study. J Invest Dermatol. 2014;134(7)1847-1854.

3. Magin P, Adams J, Heading G, Pond D, Smith W. Experiences of appearance‐related teasing and bullying in skin diseases and their psychological sequelae: results of a qualitative study. Scand J Caring Sci, 2008;22(3):430-436.

4. Vivar KL, Kruse L. The impact of pediatric skin disease on self-esteem. Int J Womens Dermatol. 2017;4(1):27-31.

5. Chernyshov PV. Stigmatization and self-perception in children with atopic dermatitis. Clin Cosmet Investig Dermatol. 2016;9:159-166.