High risk of conjunctivitis in atopic dermatitis patients

“It is important for dermatologists to be aware of this association, diagnose and manage conjunctivitis in atopic dermatitis patients, and refer patients to ophthalmology specialists when appropriate," says April Armstrong, M.D., University of Southern California, Los Angeles

Dermatologists should look for signs of conjunctivitis in their atopic dermatitis patients and learn how to manage the condition because this patients population may have an increased risk of experiencing conjunctivitis, particularly allergic conjunctivitis, according to a recent study published in Journal of Dermatological Treatment.¹

RELATED: Dupilumab-associated conjunctivitis

Atopic dermatitis and conjunctivitis appear to share a common pathogenesis. Impairment of physical barrier functions is implicated in both disorders, and previous studies have suggested that atopic dermatitis patients may be afflicted by dysfunction of the ocular surface epithelium.²

Patients with conjunctivitis may experience impairment of vision and sleep disturbances, leading to absences and reduced productivity at work or school. As patients with atopic dermatitis already experience a significant impact to their quality of life,³ there is a need for dermatologists to accurately detect and managing conjunctivitis in this patient population.

THE STUDY
Researchers used data from the National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) from 2002 to 2015 to compare rates of conjunctivitis in patients with atopic dermatitis to rates in people without this skin condition.

They found that patients with atopic dermatitis had a four fold higher risk of conjunctivitis and an eight fold higher risk of allergic conjunctivitis.

Study investigators analysed a total of 8,581,098 weighted atopic dermatitis visits and compared them against 12,853,199,920 weighted non-AD visits. The results showed that compared to adults without atopic dermatitis, the odds ratio of having conjunctivitis was 4.38 in adults with atopic dermatitis, and the odds ratio for having allergic conjunctivitis was almost double at 8.03.

RELATED: Case study: Conjunctivitis in atopic dermatitis

Two thirds (67.6%) of visits for conjunctivitis were for allergic conjunctivitis among adults with atopic dermatitis, while only a third (35.4%) for conjunctivitis were for allergic conjunctivitis among patients without atopic dermatitis.

Lead researcher April Armstrong, M.D., of the Department of Dermatology, University of Southern California, Los Angeles, says as the study showed atopic dermatitis is associated with a higher risk of conjunctivitis, and patients with atopic dermatitis treated with biologic therapies may be at greater risk of conjunctivitis.^4,5

“It is important for dermatologists to be aware of this association, diagnose and manage conjunctivitis in atopic dermatitis patients, and refer patients to ophthalmology specialists when appropriate,” she explains.

Conjunctivitis can be diagnosed with a detailed patient history and eye examination. Hyperemia of the eye is a hallmark symptom of conjunctivitis, and other symptoms include pain, pruritus and eye discharge. Pain is usually mild or absent in bacterial, viral and allergic conjunctivitis.

Continuous watery or serous discharge and pruritus, suggests allergic conjunctivitis for which treatments include topical agents such as histamine receptor antagonists, mast cell stabilizers, nonsteroidal anti-inflammatory drugs and corticosteroids.

RELATED: Atopic dermatitis patients receive more complex treatment regimens

Patients with allergic conjunctivitis should also be told to avoid allergens by limiting outdoor exposure and keeping windows closed, Dr. Armstrong says. Contact lens wearers should avoid putting on lenses because doing so may trap allergens and exacerbate symptoms, she adds.

Continuous watery or serous discharge without pruritus is most likely to be viral conjunctivitis, for which treatment is mainly supportive, including cold compresses, artificial tears and topical ocular decongestants.

Continuous and purulent discharge is most likely bacterial conjunctivitis, for which supportive treatment should again be recommended as most patients will improve within two to five days without antibiotics, says Dr. Armstrong.

Patients with conjunctivitis should be referred to ophthalmology if they report moderate-to-severe pain, photophobia or blurred vision.

LIMITATIONS
Data from the National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) used in the study only cover the three most important diagnoses, Dr. Armstrong points out.

RELATED: Atopic dermatitis and the atopic march

“Most busy clinicians would not include a diagnosis of conjunctivitis unless it was very significant or required attention. Therefore, the proportion of visits representing conjunctivitis is likely to be larger in the population, and the magnitude of positively significant associations may be even greater than what our analyses have depicted.”

Clinical trials also suggest that conjunctivitis may occur at increased rates in patients with moderate-to-severe atopic dermatitis, but clinical trials are usually highly selective so it was important to determine the risk of conjunctivitis in the wider population of atopic dermatitis patients regardless of therapy, she says.

References:

1. Wu KK, Borba AJ, Deng PH, Armstrong AW. Association between atopic dermatitis and conjunctivitis in adults: a population-based study in the United States. J Dermatolog Treat. 2019;:1-5.

2. Yokoi K, Yokoi N, Kinoshita S. Impairment of ocular surface epithelium barrier function in patients with atopic dermatitis. Br J Ophthalmol. 1998;82(7):797-800.

3. Hilton, Lisette. Adult atopic dermatitis big impact. Dermatology Times website. https://www.dermatologytimes.com/videos-atopic-dermatitis/adult-atopic-dermatitis-big-impact. Published July 11, 2019. Accessed December 12, 2019.

4. Simpson EL, Flohr C, Eichenfield LF, et al. Efficacy and safety of lebrikizumab (an anti-IL-13 monoclonal antibody) in adults with moderate-to-severe atopic dermatitis inadequately controlled by topical corticosteroids: A randomized, placebo-controlled phase II trial (TREBLE). J Am Acad Dermatol. 2018;78(5):863-871.e11.

5. Simpson EL, Bieber T, Guttman-yassky E, et al. Two Phase 3 Trials of Dupilumab versus Placebo in Atopic Dermatitis. NEngl J Med. 2016;375(24):2335-2348.