Meta-Analysis: Atopic Dermatitis Tied to Suicide Risk

Eczema, also known as atopic dermatitis (AD), is an incurable, chronic, common disease with periodic flare-ups. Symptomsopens in a new tab or window vary from person to person and can include thickened, cracked, scaly skin and itching, which may be especially severe at night. In the U.S., approximately 18 million adults (7.2%) and 9.6 million children (13.0%) are known to have this inflammatory, familial condition of the skin.

Action Points

• Patients with atopic dermatitis had a 44% increased odds of suicidal ideation and a 36% increased odds of suicide attempts compared with patients without atopic dermatitis (AD).

• Note that dermatology providers are encouraged to screen patients with AD for suicidality and refer emergent cases to appropriate resources.

  
  

Disruption of the skin barrier, a distinct inflammatory response to environmental allergens, and skin colonization with Staphylococcus aureus are among the numerous factors impacting the etiology of ADopens in a new tab or window. People with AD also tend to develop other allergic conditionsopens in a new tab or window such as allergic rhinitis and asthma. Symptom controlopens in a new tab or window of this relapsing disease can be achieved with emollients, topical corticosteroids, and calcineurin inhibitors, but different strategies may be required for treatment-resistant disease.

Prior studies have highlighted the immense psychosocial burden of AD. For instance, adult AD sufferers performed worse at work and had fewer job opportunities compared with their healthy counterparts. People with AD also were found to suffer disproportionately from anxiety and depression. Current evidence, however, has been inconclusive regarding an association between AD and suicidality.

The systematic review and meta-analysis of relevant studies by April Armstrong, MD, MPH, of the University of Southern California Keck School of Medicine in Los Angeles, and colleagues addressed what they called a gap in the literature with respect to the association between AD and suicidality.

As described in the team's study online in JAMA Dermatologyopens in a new tab or window, the researchers reviewed 15 studies conducted in Europe (n = 6), Africa (n = 1), North America (n = 1), and Asia (n = 7) published over the past 20 years, including a total of 4,770,767 participants. Among them, 310,681 were AD patients (52.7% female) and 4,460,086 served as controls (50.9% female).

All the studies were observational and examined suicidality in all its forms -- i.e., suicidal ideation, suicide attempts, and completed suicides. Assessments were made via the Carroll Rating Scale for Depression, the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition Questionnaire, the German Pöldinger Scale, the Beck Depression Inventory, and the Primary Care Evaluation of Mental Disorders, along with medical records, mortality records, and various other questionnaires; case series and case reports were excluded.

The investigators found that when compared with individuals who did not have AD, patients with the condition had a 36% greater chance of attempting suicide (pooled odds ratio 1.36, 95% CI 1.09-1.70), as well as 44% greater chance of having suicidal thoughts (pooled OR 1.44, 95% CI 1.25-1.65).

Data from the analysis showed inconsistencies when it came to completed suicides in patients with AD, the researchers noted. For example, one study showed that when compared with control participants, AD patients have a greater risk of completed suicide -- relative risk of 1.4 (95% CI 1.1-1.8). Another study showed no significant risk for completed suicides, with point estimates for hazard ratios less than 1. Overall, the pooled data did not show a clear increase in risk for completed suicides.

Studies also showed varying results for suicidal thoughts and attempts, with some indicating significant risk associated with AD across the board, whiles others found increased risk only for certain subgroups such as female children. But the pooled data did indicate a significant risk for suicidal thoughts and attempts associated with the skin condition.

Because a large number of different instruments were used among a small number of studies in the current analysis, Armstrong and colleagues noted that it was not possible "to discern the amount of heterogeneity that resulted from the differences in study instrumentation and the amount of heterogeneity that resulted from true differences in individual study results." Potential confounders included patients with other medical conditions in the control groups of some studies and the fact that few studies investigated the prevalence of completed suicides among patients with AD compared with controls.

Nackerdien, Z. (2018, December 16). Meta-analysis: Atopic dermatitis tied to suicide risk — Results suggest professionals should consider screening eczema patients. MedPage Today. https://www.medpagetoday.com/dermatology/atopy/76955