The Burden of Childhood Atopic Dermatitis in the Primary Care Setting

A Report From the Meta-LARC Consortium

Jinan Al-naqeeb, MD, MPH; Sankirtana Danner, MA, CCRP; Lyle J. Fagnan, MD; Katrina Ramsey, MPH; LeAnn Michaels; Julie Mitchell; Kelsey Branca, MPH; Cynthia Morris, PhD, MPH; Donald E. Nease, Jr., MD; Linda Zittleman, MSPH; Barcey Levy, MD, PhD; Jeanette Daly, RN, PhD; David Hahn, MD, MS; Rowena J. Dolor, MD, MHS; Hywel C. Williams, DSc, FMedSci; Joanne R. Chalmers, PhD, BSc; Jon Hanifin, MD; Susan Tofte, RN, FNP; Katharine E. Zuckerman, MD, MPH; Karen Hansis; Mollie Gundersen; Julie Block; Francie Karr; Sandra Dunbrasky, MD; Kathy Siebe, CPNP; Kristen Dillon, MD; Ricardo Cibotti, PhD; Jodi Lapidus, PhD; Eric L. Simpson, MD, MCR


J Am Board Fam Med. 2019;32(2):191-200. 

In This Article

Abstract and Introduction


Background: Little is known about the burden of atopic dermatitis (AD) encountered in US primary care practices and the frequency and type of skin care practices routinely used in children.

Objective: To estimate the prevalence of AD in children 0 to 5 years attending primary care practices in the United States and to describe routine skin care practices used in this population.

Design: A cross-sectional survey study of a convenience sample of children under the age of 5 attending primary care practices for any reason.

Setting: Ten primary care practices in 5 US states.

Results: Among 652 children attending primary care practices, the estimated prevalence of ever having AD was 24% (95% CI, 21–28) ranging from 15% among those under the age of 1 to 38% among those aged 4 to 5 years. The prevalence of comorbid asthma was higher among AD participants compared to those with no AD, namely, 12% and 4%, respectively (P < .001). Moisturizers with high water:oil ratios were most commonly used (ie, lotions) in the non-AD population, whereas moisturizers with low water:oil content (ie, ointments) were most common when AD was present.

Conclusions: Our study found a large burden of AD in the primary care practice setting in the US. The majority of households reported skin care practices that may be detrimental to the skin barrier, such as frequent bathing and the routine use of moisturizers with high water: oil ratios. Clinical trials are needed to identify which skin care practices are optimal for reducing the significant burden of AD in the community.


Atopic dermatitis (AD) is a common chronic inflammatory skin condition that usually starts in early childhood but can develop at any age.[1–3] AD represents a substantial disability burden on a global scale.[4] Large international studies reveal a wide range of prevalence rates in industrialized countries ranging between 10% to 30%, with rates varying greatly by geographic area.[5–7] US-specific studies find similar high rates of disease prevalence and similar geographic variability in prevalence.[8,9] Most of our understanding of AD prevalence in the United States stems from a limited number of national population-based surveys, which are now over 10 years old.[2,8,9] Although they provide a reasonable estimate of population prevalence, population-based studies do not always accurately reflect the burden of a disease encountered in community health care settings—an important consideration for resource allocation by decision makers.[10,11] A better understanding of the burden of AD and the associated allergic comorbidities encountered in primary care practices helps to plan disease prevention strategies appropriate to this setting. Prevention strategies that prevent AD development may also reduce allergic comorbidities that often follow AD development, such as allergic asthma.

Epidemiologic studies identify several risk factors for AD development, including climatic factors,[12] cat ownership,[13] proximity to traffic,[14] early allergen sensitization, family history of atopic diseases, and an FLG gene mutation (a gene important for proper skin barrier function).[15] In a large unselected cohort from the United Kingdom, skin barrier dysfunction as measured by transepidermal water loss at 2 days and 2 months of age was the strongest risk factor for AD development at 12 months of age, more so than an FLG mutation or family history of atopy.[15]

Because of the role early skin barrier dysfunction may play in AD development, our group and others have been interested in how skin care practices and moisturizer use may modify AD disease risk. Currently, there are no data to support the need for routine emollient use in healthy newborns.[16] However, 3 pilot trials suggest daily moisturizer therapy in high-risk populations may reduce the risk of developing AD by as much as 50%.[17–19] The optimal type of moisturizer that protects against AD in not clear, although moisturizers with higher oil content are thought to enhance skin barrier function more so than lower oil content moisturizers.[20] Because plain water and fragrances can be an irritant to skin, fragranced moisturizers with high water content may, in theory, be detrimental to skin barrier function. Some authors postulate that the increased use of fragranced lotions early in life may explain the rising epidemic of AD, although no studies have shown this association in a rigorous manner.[21]

To develop and study novel skin care interventions as a prevention strategy for AD, data are needed regarding the routine skin practices currently used by US families. In preparation for a large community-based trial evaluating moisturizers for the prevention of AD, we sought to determine the prevalence of AD in children attending primary care settings by using a convenience sample of children under the age of 5 and aimed to describe current skin care practices used by parents on their children both with and without AD.