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ISSN: Print -2349-0977, Online - 2349-4387

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Year : 2017  |  Volume : 4  |  Issue : 3  |  Page : 144-148

Childhood Atopic Dermatitis: Impact on Quality of Life in Thai Children and their Families

Department of Pediatrics, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkoknoi, Bangkok, Thailand

Date of Web Publication30-Jan-2018

Correspondence Address:
Wanee Wisuthsarewong
Department of Pediatrics, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkoknoi, Bangkok
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/astrocyte.astrocyte_27_17

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Aim: To assess the impact of atopic dermatitis (AD) on quality of life (QoL) and the factor affecting QoL in Thai children and their families. Materials and Methods: This cross-sectional study was conducted on 86 AD patients at Siriraj Hospital. AD patients aged <16 years and their families were asked to complete the Thai versions of the Infants' Dermatitis Quality of Life Index (IDQoL), Children's Dermatology Quality of Life Index (CDLQI), and Dermatitis Family Impact Questionnaire (DFI). Results: Mean age of the patients was 6.5 ± 0.5 years old and 67.4% were females. The mean ± SD of QoL scores affected by AD was 8.88 ± 5.65. QoL score was high in the group of questions related to symptoms and feelings, followed by sleep problems. The mean ± SD score for DFI was 9.94 ± 7.49. Impact on QoL in Thai children and their families was significantly correlated with disease severity (P = 0.03, r = 0.24; and P= 0.01, r = 0.30, respectively). Factors that caused negative impact on QoL of patients were taking oral medications and disease severity (P = 0.01). Factors causing negative impact on QoL of families were disease severity (P = 0.01), positive for family member with allergic diseases (P= 0.01), start attending school (P = 0.02), and taking oral medications (P = 0.04). Limitation: The limitation of the study was the disadvantage of questionnaire-based study in collecting data. Conclusions: AD caused significant impact on QoL of Thai children and their families. QoL measurement should be included in the patient care assessment to improve effective management of AD.

Keywords: Atopic dermatitis, QoL, quality of life

How to cite this article:
Wisuthsarewong W, Nitiyarom R, Boonpuen N. Childhood Atopic Dermatitis: Impact on Quality of Life in Thai Children and their Families. Astrocyte 2017;4:144-8

How to cite this URL:
Wisuthsarewong W, Nitiyarom R, Boonpuen N. Childhood Atopic Dermatitis: Impact on Quality of Life in Thai Children and their Families. Astrocyte [serial online] 2017 [cited 2020 Jun 3];4:144-8. Available from: http://www.astrocyte.in/text.asp?2017/4/3/144/224192

  Introduction Top

Atopic dermatitis (AD) is the most common chronic skin disease in children. AD is not a life-threatening illness, but it causes many symptoms, including pruritus, skin discomfort, and sleep disturbance. These symptoms adversely affect physical health and function, and they produce dramatic negative impact on quality of life (QoL) of patients and their families.[1],[2],[3],[4],[5],[6],[7],[8],[9],[10],[11],[12] AD can also cause emotional abnormalities and social dysfunctions, including feelings of stress, embarrassment, frustration, fussiness, social isolation, negative self-esteem, and poor self-image. AD may interfere with sleep, play, sports, hobbies, school attendance, and normal development of patients.[13],[14] As a consequence of this disease, family members may experience sleep disturbance, feelings of guilt, blame, worry, frustration, and financial problems.[6],[8],[14],[15],[16] Most physicians concentrate only on assessment of the clinical severity of AD, but dermatologic examination alone cannot measure psychological impact and QoL impairment caused by this condition. As a component of a holistic approach to treating this disorder, physicians should identify the adverse influences that AD has on patients and their families, including psychosocial well-being, perception of and reaction to health status, and other nonmedical aspects of patient and family life.

The aim of this study was to determine the impact of AD on QoL and the factors that affect QoL in Thai children and their families.

  Materials and Methods Top

This cross-sectional questionnaire-based study was conducted on 86 pediatric AD patients who received treatment at the Dermatology Clinic, Department of Pediatrics, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand. Parents or primary caregivers of AD patients were asked to participate in the study. The protocol for this study was approved by the Siriraj Institutional Review Board. Written informed consent was obtained from patients or guardians prior to inclusion in the study.

All patients were examined by pediatric dermatologists. Diagnosis of AD was made according to Hanifin and Rajka criteria. Clinical severity of AD was assessed using Rajka and Langeland scoring system, with total scores ranging from 0 to 9 (mild 3–4, moderate 4.5–7.5, and severe 8–9).[17]

Infants' Dermatitis Quality of Life Index (IDQoL), Children's Dermatology Life Quality Index (CDLQI), and Dermatitis Family Impact Questionnaire (DFI) were used to evaluate QoL of infants and children <4 years old, QoL of 4–16 years old, and QoL of families, respectively.[6],[13],[18] Each questionnaire contains 10 questions and each answer is graded from 0–3 for a maximum possible score of 30. A higher score indicates a greater degree of effect on QoL. These questionnaires were previously translated into Thai language and validated.[12] Thai versions of these surveys were authorized for use in this study by the original survey authors, Professor Andrew Y Finlay and Dr. MS Lewis-Jones. The IDQoL was answered by parents or proxy. Young patients who could not read answered the questions with the help from their parents.

Demographic data were analyzed using descriptive statistics. Data were presented as number and percentage or mean ± standard deviation (range). QoL scores were analyzed to identify the effects of AD and the aspects of life that were affected. QoL scores were also analyzed in groups according to problem, including symptoms and feelings, leisure, school or holiday, sleep, treatment, and personal relationships. Patients were divided into three age groups, as follows: infantile (newborns to 1 year), preschool age (>1 year to 6 years), and school age (>6 years to 15 years). Spearman's rank correlation coefficient was used to investigate relationships between QoL, DFI scores, and all other factors. Mann–Whitney U-test and Kruskal–Wallis test were used to analyze factors affecting QoL of patients and families. A P value of <0.05 was considered statistically significant.

  Results Top

Of the 86 patients enrolled in this study, 58 (67.4%) were girls and 28 (32.6%) were boys for a female: male ratio of 2.1:1. Mean age of patients was 6.5 ± 0.5 years (range 1.5 months to 16 years). Mean duration of AD was 3 years and 4 months. Ninety percent (78) of patients had mild to moderate severity. Demographic, educational, and clinical characteristics of study participants were shown in [Table 1].
Table 1: Demographic, educational, and clinical characteristics of study participants

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Mean QoL score of AD patients was 8.88 ± 5.65 (range 0–24). Fifty-eight patients (67.4%) had scores <15, and 3 patients (3.5%) had a score of 0. QoL scores analyzed by age group, disease severity of patients, and other factors were shown in [Table 2].
Table 2: QoL scores of patients and DFI scores of their families

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Factors affecting QoL of patients were disease severity (P = 0.03) and taking oral medications (P= 0.01), including the number of medications (P = 0.01) and frequency of administration (P = 0.01). Other factors, such as age, gender, duration of AD, personal history of other allergic diseases, positive for family members with allergic diseases, topical medications (corticosteroids, calcineurin inhibitors, antibiotics), and moisturizer application did not significantly affect patient QoL. QoL scores of AD patients were found to be statistically significantly correlated with AD severity (P= 0.03, r = 0.24).

When QoL was analyzed by question group, the percentage of score was highest in the group of questions related to symptoms and feelings, followed by sleep problems. Question groups relating to leisure, treatment, school or holiday, and personal relationships showed lower scores. Disease severity was correlated with scores from question groups about symptoms and feelings (P = 0.01, r = 0.35) and sleep problems (P = 0.04, r = 0.27) [Table 3].
Table 3: Percentage of quality of life scores related to questions and correlation with disease severity

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The mean ± SD score for the DFI was 9.94 ± 7.49 (range 0–26). Fifty-eight families (67.4%) had scores <15, and two families (2.3%) had a score of 0. DFI scores were high in questions that asked about tiredness/exhaustion, emotional distress, and monetary expenditures. Factors affecting DFI were taking oral medications (P= 0.04) [especially the number of medications (P = 0.01)], start attending school (P = 0.02), positive for family member with allergic diseases (P = 0.01) [especially AD (P = 0.01) and allergic rhinitis (P = 0.02)]. There was no correlation between DFI and family income (P= 0.85, r = −0.02). Other factors, including age, gender, other allergic diseases in the patients, duration of AD, and topical applications, had no significant effect on QoL of the family [Table 2]. DFI scores were statistically significantly correlated with QoL scores (P = 0.01, r = 0.64) and disease severity (P= 0.01, r = 0.30) of patients. Disease severity showed high correlation with DFI scores for housework, time spent on shopping for the family, and emotional distress [Table 4].
Table 4: Percentage of dermatitis family impact scores related to questions and correlation with disease severity

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  Discussion Top

Clinical evaluation alone does not measure all aspects or effects of a chronic disease. AD patients and their families usually experience some QoL impairment. Data and findings from this study confirmed the results of previous studies that showed AD had an adverse impact on patients and their families.[7],[9],[10],[11],[11],[15],[19],[20] According to age group and severity of the patients enrolled into the study, the result of mild degree of QoL impairment from our data may reflect childhood AD with mild to moderate severity. Like some studies,[14],[16],[17],[18],[19],[20],[21] our study also found that patients experienced problems with itching and sleep. Itching and scratching could aggravate AD lesions leading to superimposed bacterial infections.

AD patients have significant sleep abnormalities, including difficulty falling asleep, frequent nighttime awakenings, and difficult morning awakening. Insomnia and decreased total sleep time lead to daytime drowsiness, tiredness, irritability, impaired concentration, alterations in growth hormone secretion, behavior, and discipline problems.[10],[16],[19],[20],[21] Sleep problems in AD patients commonly caused negative effect on parental sleep patterns, because co-sleeping is the norm in Thailand. Some parents reported sleeping with their AD children to prevent scratching.

Taking oral medications, especially the number of medications, significantly affected QoL of patients and their caretakers. These QoL impairment may be from the correlation between the need for oral medications and the more AD severity. Many physicians prescribed oral antihistamine and systemic antibiotics to control AD aggravation. To lessen the concern about taking oral medications, oral medication should be given only with definite indication. Topical medications and moisturizers, which are very important in AD management, did not affect patient QoL. Therefore, physicians should encourage the application of moisturizer, consistent with the recommendations of many guidelines.[22],[23],[24] Patients with AD may have concomitant asthma and allergic rhinitis. From our findings, these aforementioned diseases did not interfere with patient and family QoL any more than patients and their families who experienced AD alone.

A statistically significant correlation between QoL scores and disease severity was demonstrated. The effect of AD on the family was also increased with patients with high disease severity. Similar to many reports, more severe AD caused a higher degree of QoL impairment in both patients and caretakers.[3],[4],[5],[16],[19] Effective AD management results in improved QoL for both patients and families.

Data from this study showed good correlation between patient QoL and DFI scores. Taking care of children with AD is a burden for parents and caretakers. Special patient care recommendations, such as bathing, wet dressing, topical application, and household-related tasks and responsibilities like food restrictions, cloth selection, laundry, and house cleaning to avoid potential allergens are exhausting and time-consuming. This combination of ongoing roles can have a profound effect on the QoL of caregivers.[8] As one would expect, families that have more than one member with allergic diseases experience greater QoL impairment due to compound treatments and care-related tasks.

Our data revealed significant adverse effects of AD on the family relative to time when the patient start going to school. This problem was probably related not only to AD but also to other factors that involve psychosocial adaptation to a new environment in school. Effects of age and gender on QoL vary from country to country. In the present study, age and gender had no effect on QoL of patients and families, which is similar to the findings of other studies.[5],[19] Variations in results for these factors among studies may be attributable to differences between ethnic groups and the coping ability of each family. Regarding financial perspectives, although DFI scores were high for questions that inquired about expenditure, there was no significant correlation between family income and family QoL. These relatively small and manageable financial burdens are partially due to universal healthcare coverage in Thailand. As such, most of the direct costs are supported by the government. Even though there are many hidden indirect costs associated with treating AD, management of mild to moderate cases does not result in high or unmanageable healthcare costs to the patient's family.


The limitation of this study was the disadvantage of questionnaire-based study in collecting data. The study was conducted at National Pediatric Tertiary Referral Center; therefore, the findings may not be generalizable to AD patients in general clinics.

  Conclusions Top

AD caused significant impact on QoL of Thai children and their families. The effective AD evaluation should combine measurement of both clinical severity and QoL. Multidisciplinary interventions for AD management will improve the long-term treatment outcomes.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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Rehal B, Armstrong AW. Health outcome measures in atopic dermatitis: A systematic review of trends in disease severity and quality-of-life instruments 1985-2010. PLoS One 2011;6:e17520.  Back to cited text no. 3
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Wisuthsarewong W, Nitiyarom R, Ngamcherdtrakul P. The validity and reliability of the Thai version of children's dermatology life quality index (CDLQI). J Med Assoc Thai 2015;98:968-73.  Back to cited text no. 12
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  [Table 1], [Table 2], [Table 3], [Table 4]


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