Treatment and consequences of atopic dermatitis from childhood to adulthood

Sammanfattning: Background: Atopic dermatitis (AD) is a common, itching, chronic disease from childhood up to adulthood, which requires daily treatment. The treatment goal is to achieve as the longest symptom-free periods possible. In children with AD, parents are responsible for the treatment being carried out. During adolescence, there should be a transfer of responsibility to the young person themself. To achieve treatment goals and perform self-management of AD, young people need knowledge and support from healthcare. Aim: The overall research aim of this thesis was to investigate the prevalence, treatment, and consequences of living with AD in relation to sex and AD severity in adolescence and young adulthood. Method: All studies in this thesis were based on data from the prospective population-based birth cohort BAMSE ([Barn]/Child, Allergy, Milieu, Stockholm). At approximately 2 months of age, 4,098 infants were recruited to the study. Questionnaire data regarding AD and treatment were obtained at participant aged 1, 2, 4, 8, 12, 16, and 24 years. The questionnaire definition of AD was based on a modified version of William’s criteria. Health-related quality of life (HRQoL) was examined at age 12, 16, and 24 years. Clinical examinations were carried out at 4, 8, 16, and 24 years of age. Blood samples for study of immunoglobulin E sensitization, filaggrin gene mutations, and blood lipids were obtained from almost all participants. BAMSE data were linked to the Swedish Prescribed Drug Register and Region Stockholm’s Healthcare Data Warehouse regarding dispensed topical corticosteroid (TCS) and AD-related healthcare consultations. Results: In Study I, a quantitative study, the aim was to explore the use of emollients and TCS in adolescents with AD in relation to sex and disease severity, and to study dispensing patterns of TCS. The prevalence of AD among the adolescents at 16 years of age was 10% (n = 297). Of those, 73% reported mild AD, 17% moderate, and 10% severe AD. In total, 55% of the adolescents with AD had used TCS within the preceding 12 months, with no difference between sexes. The likelihood of being treated with TCS, emollients, or a combination of these increased in adolescents with symptoms of AD (adjusted odds ratio (adj. OR) 5.97, 95% confidence interval (CI) 1.90–18.9), but not in those with more severe AD compared with mild AD (adj. OR 1.57, 95% CI 0.58–4.25). In total, 24% (n = 297) of the adolescents reported any dispensed TCS in the preceding year. In the group with current/ongoing moderate to severe AD, 24% had been dispensed a potent TCS. In Study II, a qualitative interview study, the aim was to explore young adults’ perceptions of living with AD in relation to the concept of self-management. In total, 15 young adults with persistent AD, mild to very severe, described their perceptions of living with AD. The results revealed four categories: A part of life, Difficult to get help, Limited knowledge, and Impact on my body. The respondents expressed uncertainty regarding treatment with TCS, how to self-treat, and how it affected their bodies. They felt that it was difficult to get support from healthcare, with difficulties making an appointment or getting adequate instructions about how treatment should be performed. The young adults never felt completely symptom-free but stated that they did not allow the AD to affect their daily life. In Study III, a quantitative study, the aim was to determine whether AD affects HRQoL in adolescents and young adults in a population-based setting. A further aim was to determine if use of TCS or healthcare contacts affect HRQoL. The prevalence of AD was 17.7% (n = 542) among the young adults, and higher in females than in males (20.5% vs. 14.8%, p < 0.001). HRQoL values indicated that participants with AD at 12–24 years did not consider themselves completely healthy, with an overall increased adj. OR (1.50, 95% CI 1.30–1.73). Participants with persistent AD reported more pain/discomfort and anxiety/depression than those without AD. Moreover, healthcare contacts were limited among young people with AD and with persistent AD (mean number of consultations 0.57 and 0.96, respectively) during an eight-year period between 14 and 22 years of age. In Study IV, a quantitative study, the aim was to assess associations between AD in childhood and risk factors for cardiovascular disease in young adulthood. The prevalence of AD was 18.6% (n = 420) at 24 years. Males with AD had increased body mass index (βAdj. 0.81, 95% CI 0.15–1.47), body fat percentage (βAdj. 1.19, 95% CI 0.09–2.29), systolic blood pressure (βAdj. 1.92, 95% CI 0.02–3.82), total cholesterol (βAdj. 0.14, 95% CI 0.00–0.28), and low-density lipoprotein cholesterol (βAdj. 0.15, 95% CI 0.02–0.27) compared with males without AD. No statistically significant association was seen in females. In current AD with prepubertal onset, there was a positive association with increased BMI in both males and females (βAdj. 0.89, 95% CI 0.11–1.67 and βAdj. 0.72, 95% CI 0.11–1.33, respectively). Of those with AD, 23% (n = 97) fulfilled the criteria for severe AD. A positive association was found between severe AD and overweight, of similar size in males and females. Conclusion: Adolescents with AD and even those with severe AD are undertreated. Young adults with AD are unsure of how to manage their illness. Furthermore, AD has a negative effect on HRQoL from adolescence to adulthood. In addition, young adults with AD have few healthcare consultations. Moreover, it appears that AD, especially in males, is associated with risk factors for cardiovascular disease in young adulthood. However, the results indicate that both a long duration of AD and severe AD may be associated with obesity in both males and females.