Atopic dermatitis (AD) is a common chronic inflammatory skin condition, with onset in infancy in nearly 60% of cases [1,2]. Over the past few decades, its prevalence has risen considerably, particularly in Western countries. Before 1960, only about 2–3% of children were affected, compared with 9–12% of those born after 1970 [3,4]. Beyond its physical manifestations, AD has important implications for health-related quality of life (HRQL), often disturbing sleep, limiting social interactions, and affecting school or work performance. Patients frequently experience distress and anxiety, with consequences for psychological well-being and functional capacity. The chronic and recurrent nature of AD may thus impose long-term physical, social, and psychological burdens [5,6].

The prevalence of AD has continued to increase over the last three decades [7]. Despite this, systematic assessment of quality of life (QOL) in relation to disease severity remains limited, particularly in primary care settings, where nearly 75% of skin problems are managed [8]. A major barrier has been the lack of standardized methods for measuring disease severity and its impact on QOL. It is only within the last 12 years that dermatologists have begun to address this gap [9-12].

The Children’s Dermatology Life Quality Index (CDLQI) was developed to measure the impact of skin disease on children’s lives over the preceding week [11]. In their initial validation, Lewis-Jones and Finlay reported particularly high mean scores for eczema, psoriasis, and acne, confirming the substantial burden of inflammatory dermatoses, especially AD, on childhood QOL [11].

Although the incidence and severity of AD often decline with age, around 40% of adolescents and up to 50% of adults continue to experience recurrences from childhood disease, even if symptoms are less intense [13-15]. While AD is not life-threatening, it remains an uncomfortable and highly visible condition. Ongoing daily care, the need to avoid unpredictable triggers, and the burden of persistent pruritus, which is as distressing as pain in other disorders, contribute to sleep disturbances and impaired functioning. AD is also frequently associated with other atopic conditions such as asthma, allergic rhinitis, and conjunctivitis, further compounding its impact on QOL [16].

Although several studies have highlighted the negative impact of AD on the quality of life of children and their families, these consequences are now well established [17]. However, further research is required to better delineate the relationship between disease severity and quality of life, particularly in children.

Therefore, the present study was conducted to assess the clinical profile, disease severity, and its impact on quality of life in children with atopic dermatitis attending a tertiary care hospital.

This cross-sectional study was conducted in the Department of Dermatology and Venereology, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh, from March 2007 to February 2008. In this study, we included 130 children aged 0-17 years with a confirmed diagnosis of atopic dermatitis, as determined by clinical criteria.

These were the following criteria for eligibility as study participants:

Inclusion Criteria

• Children aged 0-17 years diagnosed with atopic dermatitis.
• Children attending the outpatient or inpatient dermatology clinics during the study period.
• Written informed consent obtained from parents or legal guardians.

Exclusion Criteria

• Children with other chronic dermatological conditions (e.g., psoriasis, ichthyosis).
• Children with severe systemic illnesses or immunodeficiency disorders.
• Children whose parents or guardians were unwilling or unable to provide consent.

Data Collection Procedure: Legal guardians of diagnosed atopic dermatitis patients were asked to be included in the present study. Informed written consent was obtained after an explanation of the study procedure. Demographic and clinical information, including age, sex, residence, family history of atopy, duration of disease, and prior treatments (topical or systemic), was collected using a structured proforma. Disease severity was assessed using the SCORAD (Scoring Atopic Dermatitis) index, intensity of clinical features, and subjective symptoms such as pruritus and sleep disturbance reported by parents or children. SCORAD scores range from 0 to 103 and were classified as mild (<25), moderate (25–50), or severe (>50). The impact of atopic dermatitis on children’s daily lives was assessed using the Children’s Dermatology Life Quality Index (CDLQI), a 10-item questionnaire covering symptoms, feelings, leisure, school, sleep, treatment, and social interactions, scored 0–3 with a total score of 0–30 (higher scores indicate greater impairment). Primary outcomes included the total CDLQI score, individual component scores, and adverse daily-life outcomes, such as school absence, sleep disturbance ≥3 nights per week, and unscheduled clinic visits in the preceding six months.

Statistical Analysis: All data were systematically recorded using a pre-designed data collection form. Quantitative data were presented as means and standard deviations, while qualitative data were shown as frequency distributions and percentages. Comparisons of outcomes across severity groups were conducted using Chi-square tests for categorical variables. A p-value of <0.05 was considered statistically significant. Statistical analysis was carried out using SPSS 10 (Statistical Package for Social Sciences) for Windows, version 10. This study received ethical approval from the Institutional Review Board of Bangabandhu Sheikh Mujib Medical University (BSMMU).

Table 1: Demographic and clinical characteristics of children with atopic dermatitis

Table 1 shows that the mean age was 8.4 ± 3.6 years, with the majority belonging to the 5–9 years age group (40.0%), followed by 10–14 years (26.2%), and 0–4 years (21.5%); only 12.3% were aged 15 years or older. There was a slight male predominance (56.9% males vs. 43.1% females). Most participants resided in urban areas (66.2%), while 33.8% were from rural settings. A positive family history of atopy was reported in 44.6% of cases. The mean duration of disease was 36.2 ± 28.9 months. Regarding treatment history, 78.5% of the children had received topical steroids, while 13.8% had been treated with systemic therapy at some point.

Table 2: Disease severity based on SCORAD and associated clinical features

SCORAD = Scoring Atopic Dermatitis

In Table 2, among the 130 children with atopic dermatitis, the majority had moderate disease (44.6%), followed by mild (35.4%) and severe (20.0%) cases, with a mean SCORAD score of 8.4 ± 3.6. Pruritus was reported in the majority (95.4%) of children, while sleep disturbance was noted in 52.3%. Visible skin excoriation was present in 59.2%, and secondary bacterial infections in the past year were reported in 23.8% of participants. The most commonly affected areas were the upper and lower limbs (83.7%) and the elbows and knees (73.1%). The face and neck were affected in 55.4% of children, while the chest/abdomen and back were involved in 43.1% and 40.0%, respectively. Less frequently affected areas included the scalp (36.9%), hands/fingers (30.8%), and feet/toes (29.2%).

Table 3:  CDLQI component scores among children with atopic dermatitis

CDLQI =  Children’s Dermatology Life Quality Index

Table 3 shows that the mean total CDLQI score among 130 children with atopic dermatitis was 10.5 ± 6.0. The most affected components were scratching/itching (83.8%, mean 1.6 ± 0.9), child sleep disturbance (66.2%, 1.3 ± 1.1), and playing (62.3%, 1.2 ± 1.0). Other frequently impacted components included embarrassment (57.7%), changing clothes (55.4%), sports participation (50.0%), and school time (46.9%). Less commonly affected components were friendships (42.3%), treatment burden (40.8%), teasing (40.0%), and holiday activities (37.7%). These findings demonstrate that atopic dermatitis significantly affects multiple components of daily life, with itching and sleep disruption being the most burdensome.

Table 4: Impact of atopic dermatitis severity on daily life, school, and healthcare use

*Chi-square test of independence.

Table 4 shows that among 130 children with atopic dermatitis, adverse outcomes were significantly associated with disease severity. School absence was reported in 13.0% of mild cases, 31.0% of moderate cases, and 42.3% of severe cases (p = 0.017). Sleep disturbance occurring ≥3 nights per week was markedly more common in severe disease (76.9%) compared to moderate (51.7%) and mild cases (17.4%) (p < 0.001). Similarly, unscheduled clinic visits in the preceding 6 months were required by 26.1% of mild cases, 46.6% of moderate cases, and 61.5% of severe cases (p = 0.009).

Atopic dermatitis (AD) is one of the most common chronic skin disorders in childhood, affecting between 5% and 20% of children worldwide [18,19]. In Singapore, a large study of 12,323 schoolchildren aged 7 to 16 years reported a prevalence of 21% in a predominantly Asian population [20]. Similarly, a cross-sectional study from Northern Europe demonstrated a prevalence of 15.6% among children using an investigator-developed questionnaire, which was validated against Hanifin and Rajka’s criteria [21]. Laughter et al reported a prevalence of 17% in Oregon schoolchildren, although the use of stricter diagnostic thresholds yielded a more conservative estimate of 7% [19]. These variations highlight the methodological challenges in determining the true prevalence of AD through population-based questionnaires. Although AD may persist into adulthood, childhood disease remains far more common, and approximately 60% of patients achieve remission by adulthood [22].

In the present study, the most frequently affected quality of life components, as assessed by the Children’s Dermatology Life Quality Index (CDLQI), were itching (83.8%), sleep disturbance (66.2%), and limitations in play activities (62.3%). These findings reinforce the significant impact of AD on daily life, with pruritus and sleep disruption emerging as the most burdensome symptoms. Ben-Gashir et al similarly observed that itching contributed the highest proportion of CDLQI scores, with nearly three-quarters of children experiencing itchy, painful, or uncomfortable skin [23]. This pattern is consistent with the original validation of the CDLQI, where symptoms and feelings were the domains most strongly affected [11,23].

The CDLQI has proven to be a valuable tool in assessing the psychosocial burden of dermatologic conditions in children. Studies have shown that not only AD, but also other chronic skin disorders such as vitiligo, negatively influence quality of life, with improvements in disease activity correlating with reductions in CDLQI scores [24]. More recent work has confirmed that AD significantly impairs the quality of life of both children and toddlers, particularly in the domains of itch, self-consciousness, dressing, sleep, and treatment-related difficulties [25–27]. In these studies, at least 60% of children reported being affected to some degree by their skin disease, and up to 85% of toddlers experienced substantial disruption across multiple domains [25]. Ben-Gashir et al [23] also demonstrated that quality of life impairment correlated closely with AD severity, further supporting the utility of the CDLQI in community-based research.

In our cohort, most children presented with moderate disease (44.6%), followed by mild (35.4%) and severe (20.0%), with a mean SCORAD score of 8.4 ± 3.6. Pruritus was reported in the majority of cases (95.4%), while sleep disturbance affected over half (52.3%). Similar to our findings, Emerson et al [27] and Lewis-Jones et al [28] reported low quality of life scores in children with eczema, though differences in study design and outcome measures limit direct comparison. Nonetheless, these results consistently demonstrate that AD exerts a substantial burden on children and their families, even in the absence of active eczema lesions [23].

The psychosocial implications of AD extend beyond symptoms. Children with atopic dermatitis often experience behavioral difficulties, including increased dependency, fearfulness, and disturbed sleep [29]. Such problems may interfere with social and intellectual development, with peer and teacher interactions sometimes compromised by concerns about appearance, fear of contagion, or restrictions in physical activities [30]. Sleep disruption, largely due to nocturnal itching and scratching, is particularly significant. Yosipovitch et al [31] reported that 84% of AD patients had difficulty falling asleep and 79% experienced nocturnal awakenings due to pruritus. Objective sleep studies using actigraphy confirm these findings, showing increased nighttime activity and poorer sleep quality in children with AD compared to controls [32]. Reid et al further estimated that affected children may lose up to 2 hours of sleep per night. Such chronic sleep loss contributes to daytime somnolence, impaired school performance, and mood disturbances, while the use of sedating antihistamines can compound these effects [33].

Overall, our findings highlight the substantial morbidity associated with childhood AD. The interplay of pruritus, sleep disturbance, and psychosocial impairment underscores the need for comprehensive management strategies that address not only disease severity but also the broader quality of life of affected children and their families.

This study was conducted in a single tertiary care center, which may limit the generalizability of the findings. The cross-sectional design does not allow for assessment of long-term disease impact or causality. Recall bias may have influenced parent-reported outcomes such as school absence and sleep disturbance.

Atopic dermatitis in children is not only a common dermatological condition but also a significant contributor to impaired quality of life, particularly in those with moderate to severe disease. Itching, sleep disturbance, and functional limitations such as school absence were the most notable challenges. These findings highlight the importance of early diagnosis, patient and caregiver education, and a multidisciplinary approach to management in order to reduce disease burden and improve outcomes.

Further study with a prospective and longitudinal study design, including a larger sample size, needs to be done to validate the findings of this study.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: This study was ethically approved

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