Associations of Demographics, Aggravating Factors, Comorbidities, and Treatments with Atopic Dermatitis Severity in China: A National Cross-Sectional Study

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Associations of Demographics, Aggravating Factors, Comorbidities, and Treatments with Atopic Dermatitis Severity in China: A National Cross-Sectional Study

Atopic dermatitis (AD) is a chronic inflammatory skin disorder affecting populations globally, yet its clinical characteristics and patient demographics in China remain insufficiently characterized. This study presents a comprehensive analysis of 16,838 AD patients across China, offering insights into disease severity distribution, associated comorbidities, aggravating factors, treatment patterns, and their correlations with age, gender, and geographic regions.

Study Design and Population

Conducted from August 2021 to September 2022, this cross-sectional study enrolled patients from 205 hospitals spanning 30 Chinese provinces. AD diagnosis followed the Williams Diagnostic Criteria, with disease severity classified using the Investigator’s Global Assessment (IGA) scale: mild (IGA ≤2), moderate (IGA=3), and severe (IGA=4). Participants completed dermatologist-led surveys assessing medical history, comorbidities, aggravating factors, and treatments. Statistical analyses employed two-level mixed-effects ordered logistic regression to evaluate associations between variables and AD severity, adjusting for confounders such as gender, age, and geographic region.

Demographic and Clinical Characteristics

The cohort (mean age 30.9 ±24.1 years) comprised 54.91% males and 45.09% females. Severity distribution was 35.72% mild, 49.51% moderate, and 14.77% severe. Age-stratified analysis revealed increasing severity with age: infants (<2 years) had the lowest proportion of severe cases (9.15%), while older adults (≥60 years) had the highest (26.56%). Males exhibited higher severe AD prevalence (16.91% vs. 12.14% in females). Notably, patients with late-onset AD (≥60 years at onset) showed the highest severe AD rate (26.73%). Geographic variations emerged, with northern China reporting higher severe AD prevalence compared to western regions.

Comorbidities and Their Associations

Atopic comorbidities were prevalent: 60.95% of patients had no comorbidities, 29.02% had one, and 10.03% had multiple. Allergic rhinitis was the most common atopic comorbidity (28.94% in severe AD), followed by food allergies (7.54%), asthma (5.81%), and chronic urticaria (2.71%). Mixed-effects models identified food allergies as a risk factor for severity (OR=1.21, 95% CI:1.06–1.37), while chronic urticaria showed a protective association (OR=0.74, 95% CI:0.63–0.87).

Metabolic comorbidities included hypertension (6.89% in severe AD), diabetes (3.06%), and coronary heart disease (1.64%). Hypertension (OR=1.61, 95% CI:1.35–1.93) and diabetes (OR=1.64, 95% CI:1.27–2.12) significantly correlated with increased AD severity.

Aggravating Factors

Seasonal factors, particularly summer (OR=1.23, 95% CI:1.04–1.46), exacerbated AD severity. Food-related triggers included fish/shellfish (OR=1.64, 95% CI:1.35–1.98), lamb/beef (OR=2.01, 95% CI:1.59–2.56), chili peppers (OR=1.52, 95% CI:1.19–1.95), and alcohol (OR=1.83, 95% CI:1.36–2.48). Age-specific analyses revealed stronger associations for fish/shellfish and lamb/beef in infants and adults, while chili/alcohol effects were prominent in adults.

Environmental factors like sunlight (OR=1.79, 95% CI:1.42–2.25), humidity (OR=1.61, 95% CI:1.23–2.11), sweat (OR=1.27, 95% CI:1.08–1.48), and dust (OR=1.55, 95% CI:1.24–1.92) worsened AD. Psychological factors—stress (OR=1.99, 95% CI:1.59–2.50), emotional problems (OR=1.80, 95% CI:1.44–2.26), and sleep disorders (OR=1.89, 95% CI:1.49–2.41)—were strongly linked to severe AD.

Health-Related Outcomes

Patient-reported outcomes worsened with severity. Weekly average Numeric Rating Scale Itch Intensity (NRSI) scores were 4.7±2.8 (mild), 6.3±2.3 (moderate), and 7.5±1.9 (severe). Sleep Disturbance Scores (SDS) showed 46.47% of severe AD patients experiencing daily disruptions, compared to 15.13% in mild cases. Dermatology Life Quality Index (DLQI) and Hospital Anxiety and Depression Scale (HADS) scores similarly escalated with severity, underscoring the psychosocial burden of AD.

Treatment Patterns

Topical glucocorticoids (32.26%) and oral antihistamines (28.66%) were the most prescribed therapies, followed by moisturizers (19.58%). Despite international guidelines recommending immunomodulators for severe AD, usage rates remained low: topical calcineurin inhibitors (5.99%), dupilumab (5.80%), cyclosporine (0.82%), and methotrexate (0.54%). Systemic steroids were used by 8.51% of severe AD patients, highlighting potential mismanagement risks. Phototherapy utilization was minimal (0.76% for NB-UVB).

Discussion

This study highlights critical gaps in AD management within China. The high prevalence of severe AD among older adults suggests age-related immunological shifts or cumulative environmental exposures. The association between metabolic comorbidities (hypertension, diabetes) and AD severity aligns with global findings, implicating systemic inflammation as a shared pathway.

The dominance of antihistamines and systemic steroids, despite limited efficacy and safety concerns, points to insufficient adherence to evidence-based guidelines. Low usage of targeted therapies like dupilumab and immunomodulators may reflect cost barriers, limited access, or physician hesitancy.

Geographic severity disparities—higher in northern China—may stem from climatic factors (e.g., low humidity, temperature extremes) exacerbating skin barrier dysfunction. Regional allergen profiles, such as pollen in southern China, could further modulate disease expression.

Conclusion

This nationwide study provides the first comprehensive profile of AD in China, emphasizing the interplay of demographic, environmental, and comorbid factors in disease severity. Key findings include the rising severity with age, undertreatment with guideline-recommended therapies, and the significant burden of metabolic and psychological comorbidities. Addressing these challenges requires multidisciplinary strategies integrating patient education, healthcare provider training, and policy interventions to improve access to advanced therapies. Future research should explore longitudinal trends and mechanistic links between AD and systemic diseases.

doi.org/10.1097/CM9.0000000000003042

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