MONTREAL — Systemic treatment of atopic dermatitis (AD) boosts mood in addition to relieving skin symptoms, according to a prospective, real-world, clinical cohort study presented at the annual meeting of the International Society of Atopic Dermatitis.
“Randomized, controlled, phase 3 studies have shown that systemic treatment of AD reduces depressive symptoms, but whether this holds true in real-world cohorts remains to be shown,” said study investigator Lina Ivert, MD, PhD, of the dermatology and venereology unit, in the department of medicine at the Karolinska Institutet, Stockholm.
The study used data from SwedAD, a newly launched web-based Swedish national registry of patients with AD on systemic treatment between June 2017 and August 2021. Participants were followed at 6 and 12 months for the primary outcome of depressive symptoms using the Montgomery–Åsberg Depression Rating Scale–self-report (MADRS-S). Secondary outcomes included the Eczema Area and Severity Index (EASI) score, Patient-Oriented Eczema Measure (POEM), the Dermatology Life Quality Index (DLQI), and pruritus visual analog scale/numeric rating scale (VAS/NRS).
At baseline, 120 patients (median age 39 years; 57.5% men), were started on dupilumab (N = 91), methotrexate (26), or ciclosporin (3). Although almost half had no depression at baseline, mild depression was present in 29.2%, with moderate and severe depression in 20% and 4.2%, respectively.
Among 59 patients with 6-month follow-up data (48 on dupilumab, 10 on methotrexate, one on ciclosporin), all nine depressive symptoms in MADRS-S improved significantly, with reduced sleep improving the most (from a median of 3 points to a median of 1 point). Similarly, overall MADRS-S scores improved (from a median of 14 points to a median of 5; P < .001), as did EASI scores (from a median of 20.5 to 2), POEM scores (from a median of 22 to 6), DLQI (from a median of 15 to 3), and pruritis scores (from a median of 7.1 to 1.8; all P < .001).
The analysis also found a strong correlation between the MADRS-S score and all of the secondary outcomes (P < .001 for all). All these improvements remained significant among the 36 patients with 12-month follow-up data.
“The median MADRS-S reduction also remained when we excluded eight patients who were on antidepressants during the study period, so these results cannot be explained by psychiatric medication,” noted Ivert, adding that three patients with severe suicide ideation at baseline improved their MADRS-S suicide item to less than 2 points. “So, this study taught us to look at the suicide item score and not only the total MADRS-S score,” she commented.
Comparing patients treated with dupilumab with those treated with methotrexate, the analysis showed that though baseline median MADRS-S scores did not differ significantly between them, there was a significant 6-month reduction in the dupilumab group but not in the methotrexate group.
Asked to comment on the findings, moderator Marissa Joseph, MD, a pediatric dermatologist at the University of Toronto, Ontario, Canada, said that “the mental health effects of inflammatory skin conditions like atopic dermatitis are well known, but whether or not they are well explored in the patient-physician interaction is a whole other scenario.” There are time constraints, she said, adding, “it sometimes takes some deep-diving…but exploring those types of symptoms is something we need to do more of, and the severity of the disease and reasons for treatment are not just what you can see.”
Joseph pointed out that taking the deep dive also involves being prepared for what comes up. “Once you’ve established there’s a mental health issue, what do you do then?” she said. “If you are a dermatologist, is that in your wheelhouse to address? There’s the education and connection piece for the physician, creating networks where — if you identify a patient who has an issue — who is a person I can send them to? We have these types of connections with infectious disease or with ophthalmologists if there are ocular symptoms, but mental health is one area where there may not be as much support for dermatologists.”
She noted that though all doctors learn how to screen for depression, “there’s the formulaic, yes/no answers, and then there’s the nuanced history-taking, creating a safe space, where the patient is going to answer you fulsomely…and feel heard. Many of us know how to do that. The question is time.”
Ivert had no disclosures connected to this study. Joseph had no disclosures.
International Society of Atopic Dermatitis (ISAD) 2022: Abstract OL.18, Presented October 18, 2022.
Kate Johnson is a Montreal-based freelance medical journalist who has been writing for more than 30 years about all areas of medicine.