The burden of head-and-neck dermatitis in adults with atopic dermatitis and its association with asthma, rhinitis, and disease severity

To the Editor: Atopic dermatitis (AD) affects various body parts, including the head-and-neck area.1Patruno C. Potestio L. Napolitano M. Clinical phenotypes of adult atopic dermatitis and related therapies.Curr Opin Allergy Clin Immunol. 2022; 22: 242-249Crossref PubMed Scopus (31) Google Scholar AD in the head-and-neck area is more strongly associated with quality-of-life impairment than other locations and represents a difficult area to treat, even with biologics.2Lio P.A. Wollenberg A. Thyssen J.P. et al.Impact of atopic dermatitis lesion location on quality of life in adult patients in a Real-world study.J Drugs Dermatol. 2020; 19: 943-948Crossref PubMed Scopus (14) Google Scholar,3Gori N. Ippoliti E. Peris K. Chiricozzi A. Head and neck atopic dermatitis: still a challenging manifestation in the biologic era.Expert Opin Biol Ther. 2023; 23: 575-577Crossref PubMed Scopus (3) Google Scholar Therefore, we investigated prevalence, clinical characteristics, and burden in AD patients with and without head-and-neck dermatitis (HND) from the Danish Skin Cohort. Data collection (03/15/2018 to 07/15/2018) and content validation have been described previously.4Egeberg A. Griffiths C.E.M. Williams H.C. Andersen Y.M.F. Thyssen J.P. Clinical characteristics, symptoms and burden of psoriasis and atopic dermatitis in adults.Br J Dermatol. 2020; 183: 128-138Crossref PubMed Scopus (49) Google Scholar For full methods and results section, see online supplementary material, available via Mendeley at https://doi.org/10.17632/8wc363kshw.1. We presented frequencies with percentages for categorical variables and means with standard deviations (SDs) or medians with interquartile ranges (IQR) as appropriate. Associations between patient characteristics and HND were assessed using logistic regression models. We presented results as odds ratios (ORs) with 95% confidence intervals (95% CIs) using SAS v9.4 (SAS Institute Inc.) and Stata v15.0 (StataCorp) (Fig 1) . The study comprised a total of 3834 adults with AD (Table I). The HND prevalence was 41.9% (n = 1607) and increased with increasing AD severity (mild 24.5%, moderate 69.0%, severe 86.0%). Stratified by presence or absence of asthma or rhinitis, HND was significantly more common in AD patients with asthma or rhinitis than in AD patients without asthma or rhinitis (asthma vs no-asthma 52.1% vs 35.7%, P < .001; rhinitis vs no-rhinitis 52.0% vs 32.3%, P < .001; asthma and rhinitis vs no asthma or rhinitis 56.3% vs 29.5%, P < .001) (Supplementary Fig 1, available via Mendeley at https://doi.org/10.17632/8wc363kshw.1). Further, patch testing was performed more frequently in AD patients with HND compared to patients without HND (38.9% vs 29.9%, P < .001). Median DLQI was significantly higher in patients with than without HND (5 [IQR 2-9] vs 1 [IQR 0-4]). Skin pain (median [IQR]) was higher (3 [1-6] vs 0 [0-3]), and itch was greater (5 [2-7] vs 1 [0-4]) in patients with versus without HND (adjusted P-values <.0001). For European Quality of Life 5-Dimensions 5-Level, all data points were significantly different, showing impairment in AD patients with HND compared with AD without HND (Supplementary Fig 2 and Table I, available via Mendeley at https://doi.org/10.17632/8wc363kshw.1). In crude analyses, younger age, greater AD severity, asthma, and rhinitis were associated with HND (P-values <.0001), whereas no association was observed for sex. Adjusted effect sizes were slightly attenuated, but age (OR 0.98, 95% CI 0.97-0.98), AD severity (OR 1.09, 95% CI 1.09-1.10), asthma (OR 1.42, 95% CI 1.22-1.65), and rhinitis (OR 1.50, 95% CI 1.28-1.76) remained significantly associated.Table ICharacteristics of the study populationWithout head-and-neck dermatitis(n = 2227)With head-and-neck dermatitis(n = 1607)Age, mean (SD)51.1 (14.5)45.6 (13.9)Sex, n (%) Women1526 (68.5)1118 (69.6) Men701 (31.5)489 (30.4)Smoking, n (%) Daily smoker294 (13.3)194 (12.1) Occasional smoker84 (3.8)77 (4.8) Former smoker780 (35.2)486 (30.2) Never smoker1047 (47.2)844 (52.5) Unknown12 (0.5)6 (0.4)PO-SCORAD, mean (SD)12.9 (12.7)30.3 (13.4)Asthma, n (%)702 (31.5)762 (47.4) Well-controlled asthma, n/N∗Data on asthma control were assessed by ACQ-5 in a subset (n = 436) of patients with asthma. (%)133/191 (69.6)155/245 (63.3)Rhinitis, n (%)900 (40.4)973 (60.6)Body mass index, n Underweight (BMI <18.5)39 (1.8)36 (2.2) Normal weight (BMI 18.5-25)1052 (47.2)798 (49.7) Overweight (BMI 25-30)721 (32.4)523 (32.6) Moderately obese (BMI 30-35)245 (11.0)160 (10.0) Severely obese (BMI 35-40)89 (4.0)48 (3.0) Very severely/morbidly obese (BMI >40)44 (2.0)29 (1.8) Unknown37 (1.7)13 (0.8)Well-controlled asthma is defined as ACQ-5 <0.75.ACQ-5, Asthma Control Questionnaire - 5; BMI, body mass index; PO-SCORAD, patient-oriented scoring atopic dermatitis.∗ Data on asthma control were assessed by ACQ-5 in a subset (n = 436) of patients with asthma. Open table in a new tab Well-controlled asthma is defined as ACQ-5 <0.75. ACQ-5, Asthma Control Questionnaire - 5; BMI, body mass index; PO-SCORAD, patient-oriented scoring atopic dermatitis. No patients had been treated with dupilumab or Janus kinase inhibitors, therefore we could not estimate the effect on HND. Danish residents are predominantly Caucasian which may affect generalizability. The study was limited to adult patients and extrapolation to adolescents or children should be done with caution. In conclusion, HND is prevalent in adults with AD and associated with younger age, severe AD, asthma, rhinitis and reduced quality of life (QOL). The increased burden of HND in AD underline that clinicians should consider the best treatment for affected patients and possibly earlier resort to more aggressive therapy. With no relation to the present manuscript, Dr Rønnstad has received research funding from the Department of Clinical Medicine, Copenhagen University. With no relation to the present manuscript, Prof. Thomsen has received research support from Janssen, LEO Pharma, Novartis, Sanofi and UCB, and has been a speaker/consultant for AbbVie, Eli Lilly, Janssen, LEO Pharma, Novartis, Pfizer, Sanofi, Symphogen, UCB, and Union Pharmaceuticals. With no relation to the present manuscript, Prof. Thyssen has been an advisor for AbbVie, Almirall, Arena Pharmaceuticals, OM Pharma, Aslan Pharmaceuticals, Union Therapeutics, Eli Lilly & Co, LEO Pharma, Pfizer, Regeneron, and Sanofi-Genzyme, a speaker for AbbVie, Almirall, Eli Lilly & Co, LEO Pharma, Pfizer, Regeneron, and Sanofi-Genzyme, and received research grants from Pfizer, Regeneron, and Sanofi-Genzyme. He is currently an employee of LEO Pharma. With no relation to the present manuscript, Prof. Egeberg has received research funding from Almirall, Pfizer, Eli Lilly, Novartis, Bristol-Myers Squibb, AbbVie, Janssen Pharmaceuticals, Boehringer Ingelheim, the Danish National Psoriasis Foundation, the Simon Spies Foundation, and the Kgl Hofbundtmager Aage Bang Foundation, and honoraria as consultant and/or speaker from Amgen, AbbVie, Almirall, Leo Pharma, Zuellig Pharma Ltd, Galápagos NV, Sun Pharmaceuticals, Samsung Bioepis Co, Ltd, Pfizer, Eli Lilly and Company, Novartis, Union Therapeutics, Galderma, Dermavant, UCB, Mylan, Bristol-Myers Squibb, McNeil Consumer Healthcare, Horizon Therapeutics, Boehringer Ingelheim, and Janssen Pharmaceuticals.