Hassab-El-Naby, Hussein M.M.a; Mohamed, Yaser F.a; Ammar, Morsy A.b; Mostafa, Amr M.c
aDepartments of Dermatology
bCommunity Medicine and Public Health, Al-Azhar University
cDepartment of Dermatology, Al-Hussein University Hospital, Cairo, Egypt
Correspondence to Hussein M.M. Hassab-El-Naby, MD, Dermatology and Venereology, Al-Azhar University, Cairo, Egypt Tel: +202 24199089; fax: +202 24199089; e-mail: email@example.com
Received May 2, 2009
Accepted June 15, 2009
Background: Atopic dermatitis (AD) is a disease of great morbidity, and its incidence seems to be increasing. AD has a great impact on the lives of affected patients.
Objective: To study the effect of AD on the quality of life (QOL) of school children in a locality in Cairo.
Methods: One hundred school children between 6 and 12 years of age suffering from AD were included in the study. Disease severity was estimated using the SCORing Atopic Dermatitis (SCORAD) index. The Children's Dermatology Life Quality Index was used to evaluate the effect of AD on the QOL. The results were statistically analyzed using SPSS software (IBM Inc., Somers, NY, USA).
Results: Of the 100 children with AD (50 boys and 50 girls), 76 showed affected QOL. QOL correlated with the SCORAD index. The different aspects of life of children with AD were significantly affected by disease severity.
Conclusion: We have shown a significant correlation between severity of AD and all aspects of life of the affected children. We recommend including QOL measures as a part of the assessment of AD, which may provide additional resources for understanding and managing the disease.
Patients with skin diseases experience a wide range of symptoms, which affect their lives, ranging from trivial problems to major handicaps . Atopic dermatitis (AD) greatly affects the quality of life (QOL) of affected children and their families. The effect of AD on the QOL of school children and their families is an important issue. The psychological, physical, and social impact of AD is complex and varies among children of different ages. Quantification of QOL related to disease severity is important in patients with AD, because the assessment provides additional information to the traditional objective clinical scoring systems and an understanding of the impact of disease is necessary in the patients' management. Only by understanding actual morbidity is it possible to achieve the free flow of relevant information for diagnosis and prescription, as well as subsequent adherence to therapy . Several studies have been published in western countries studying the effect of AD on QOL [3–5]; however, there are no published data from Middle Eastern countries. The aim of this study was to evaluate the effect of AD on QOL in a community-based study over a 5-month period in a locality in Cairo.
Patients and methods
Patients were recruited through the Outpatient Clinic of Dermatology, Al-Hussein University Hospital, Cairo, Egypt during the period from January to May 2006. This hospital provides health care facilities to a city population in Al-Darrasa district, Cairo. The patients were 100 children within the age of 6 to 12 years suffering from AD. Patients with concomitant skin diseases were excluded from the study.
Children's quality of life
In this study we used the Arabic version of the Children's Dermatology Life Quality Index (CDLQI) . Young children were capable of answering the questions with some simplification by the investigator, whereas the older children were asked to answer the questions directly. Parents were also asked to help their children in answering the questions in CDLQI. The CDLQI was calculated by summing the score of each question resulting in a maximum of 30 and a minimum of 0. The higher the score, the more impaired the QOL. The output of CDLQI was divided into high QOL (0–10), intermediate QOL (11–20), and poor QOL (21–30).
The severity of AD in children was assessed using the SCORing Atopic Dermatitis (SCORAD) index . An investigator, other than the person evaluating the CDLQI, evaluated the SCORAD in the children with AD.
All statistical analyses were conducted using SPSS statistical software, version 12 (IBM Inc., Somers, New York, USA). Frequencies, cross-tabulation, and χ2 tests were carried out to analyze the relationship among different variables. Statistical significance was assumed if P value was less than or equal to 0.05.
The study included 100 patients (50 boys and 50 girls) with a mean age of 8.5 years.
Quality of life assessment
In the majority of children (76 patients) the QOL was found to be affected; 53 had an intermediate QOL, whereas 23 had a poor QOL (Table 1). Forty boys and 36 girls with nonstatistically significant difference had affected QOL (Table 2).
Quality of life and family history (Table 3)
Sixty of 100 patients reported a history of AD in one or more of their family members. Patients with a family history of AD showed a slightly better QOL than those with a negative family history, a difference that was statistically insignificant.
Quality of life and the socioeconomic status (Table 4)
The better the socioeconomic standard the lesser was the impact of the disease on the patient's life. However, this was statistically nonsignificant.
Quality of life and disease severity (Table 5)
Assessment of SCORAD index in the studied group showed that 12 of them had a mild, 59 had a moderate, and 29 had a severe form of AD. QOL showed strongly significant deterioration with increase in disease severity. Patients with a mild form of AD had a higher QOL than those with severe disease, with a statistically high significant relationship.
Disease severity and symptoms and feelings (Table 6)
Symptoms and miserable mood changes of patients increased significantly with increase in disease severity compared with controls.
Disease severity and leisure time (Table 6)
The severity of AD influenced the leisure time of the affected children negatively compared with controls.
Disease severity and school attendance (Table 6)
School attendance of the affected children became irregular with increase in disease severity compared with controls.
Disease severity and interpersonal relationship (Table 6)
The interpersonal relationship between children with AD and their friends and colleagues was markedly affected by the increased severity of the disease compared with controls.
Disease severity and sleep rhythm (Table 6)
It was clear that the increase in disease severity in patients caused the sleep rhythm to be more disturbed and irregular compared with controls.
Disease severity and treatment difficulties (Table 6)
There was an increase in treatment difficulties with an increase in disease severity in patients compared with controls.
Studies on the relationship between disease severity of AD, and QOL are conflicting. Several studies have shown that there is not always a simple relationship between the extent of skin diseases and the resulting degree of handicap  whereas others have found that severity of AD affects the patients' QOL [4,5].
In this study, QOL was assessed in patients with AD with one dermatology-specific questionnaire: CDLQI. The severity of AD was measured for patients using the SCORAD, which is an objective index.
The QOL of the group of children that was studied was markedly affected by their skin condition. The study showed no statistical difference in the QOL of patients with AD with regard to their sex, unlike the study by Holm et al. , who found a greater impact of AD on the QOL of adult female patients than adult male patients. This may be attributed to the concern of adult female patients about their look and over the feeling of embarrassment and depression because of their skin condition. Patients with a positive family history showed better QOL than those with a negative family history, but the relationship was statistically insignificant. The better the socioeconomic standard, the lesser was the impact of the disease on the patient's life; however, the result was statistically insignificant.
The QOL showed a very strong and significant deterioration with an increase in disease severity; that is, the milder the disease the higher the QOL, and the more aggressive it gets the poorer the life quality. Similar results were reported by Ben-Gashir et al. . Mood changes increased with the increase in disease severity, which may manifest as high anxiety, depression, anger, and hostility. Severity of disease negatively influenced the leisure time of our patients. This is similar to the results of Chamlin et al.  who attributed it to the parents' worries about factors that may exacerbate the disease, and therefore parents usually restrict their children from swimming or playing outdoors. School attendance became irregular with increase in disease severity. Tiredness from loss of sleep affects schoolwork, causing impaired concentration, and children with severe eczema may lose time from school. In a US survey on AD, the parents of 429 children up to the age of 15 years, reported difficulties with school performance and daily social and leisure activities in 60% of the children, which related to perceived disease severity. All these factors have an inevitable negative effect on education and may lead to the child becoming withdrawn or exhibiting difficult behavior and even lead to the development of school avoidance/phobia . Interpersonal relationships were affected with the increase of disease severity. AD has one of the greatest effects on the child's QOL, disrupting family and/or social relationships and interfering with daily activities and normal development. Peer and teacher acceptance may be affected by the appearance of the child and concerns about infectivity. These problems can lead to environmental, social, and emotional deprivation . With the increase of disease severity, sleeping rhythm became more disturbed and irregular in our patients. Chamlin et al.  reported that children with sleep disturbances were more likely to have a higher SCORAD index than those without sleep disturbance, and similarly, their parents were more likely to report sleep disturbance as well. There was an increase in problems with regard to treatment with the increase in disease severity. Lewis-Jones and Finlay  reported that there is dissatisfaction with messy treatments or bandages, and having to wear particular cotton clothes rather than synthetics. Lawson et al.  found that the majority of parents did not rate personal financial costs as the most important aspect of life affected, but single-parent low-income families found this to be one of the most important negative aspects of caring for a child with AD.
We can conclude that AD has been shown to have the potential for profound and far-reaching effects on all aspects of the lives of children and their families, particularly in those cases of severe disease. Including QOL measures as a part of the assessment of AD is recommended. This will provide essential additional information and enable us to supply resources for future disease management.
There is no conflict of interest.
1. Chamlin SL, Frieden IJ, Williams ML, Chren MM. Effects of atopic dermatitis on young American children and their families. Pediatrics. 2004;114:607–611
2. Lewis-Jones S. Quality of life and childhood atopic dermatitis: the misery of living with childhood eczema. Int J Clin Pract. 2006;60:984–992
3. Charman C, Williams H. Outcome measures of disease severity in atopic eczema. Arch Dermatol. 2000;136:763–769
4. Drake L, Prendergast M, Maher R. The impact of tacrolimus ointment on health-related quality of life of adult and pediatric patients with atopic dermatitis. J Am Acad Dermatol. 2001;44:S65–S72
5. Salek MS, Finlay AY, Luscombe DK, Allen BR, Berth-Jones J, Camp RD, et al. Cyclosporin greatly improves the quality of life of adults with severe atopic dermatitis. A randomized, double-blind, placebo-controlled trial. Br J Dermatol. 1993;129:422–430
7. European Task Force on Atopic Dermatitis. . Severity scoring of atopic dermatitis; the SCORAD Index. Consensus Report of the European Task Force on Atopic Dermatitis. Dermatology. 1993;186:23–31
8. Holm EA, Esmann S, Jemec GB. Does visible atopic dermatitis affect quality of life more in women than in men? Gend Med. 2004;1:125–130
9. Ben-Gashir MA, Seed PT, Hay RJ. Are quality of life and diseases severity related in childhood atopic dermatitis? J Eur Acad Dermatol Venereol. 2002;16:455–462
10. Paller AS, McAlister RO, Doyle JJ, Jackson A. Perceptions of physicians and pediatric patients about atopic dermatitis, its impact, and its treatment. Clin Pediatr. 2002;41:323–332
11. Lewis-Jones MS, Finlay AY. The children's dermatology life quality index (CDLQI©): initial validation and practical use. Br J Dermatol. 1995;132:942–949
12. Lawson V, Lewis-Jones MS, Finlay AY, Reid P, Owens RG. The family impact of childhood atopic dermatitis: the dermatitis family impact questionnaire. Br J Dermatol. 1998;138:107–113