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


We estimated the prevalence of AD among children age 0 to 5 attending community-based primary care practices to be approximately 24%, with a mean age of AD onset in the first year of life. Parents reported that AD severity was mild in more than half of participating children, and 20% of those with AD had their sleep disturbed at least once a week as a result of their AD. As anticipated, a higher prevalence of AD-associated comorbidities and a family history of atopic conditions were found among those with AD. The majority of parents were using some kind of moisturizer on their child's skin on a regular basis; children with AD were more likely to receive creamy and oily moisturizers, whereas children without AD were receiving lotions primarily. This large community-based study is the first study to describe the pediatric AD burden within community-based primary care practices and provides important insight into skin care practices that may be modifiable in future disease prevention studies.

A higher prevalence of AD (24%) was found in children under the age of 5 in our study compared to US population-based studies using data from the National Survey of Children Health. Shaw et al.[8] found prevalence rates ranging between 13.12% and 14.73% among those under the age of 4. Similar to our findings, previous studies of chronic illnesses found a higher prevalence rate in the primary care setting than in the population setting.[10,11] Measuring the prevalence of AD in children attending primary care clinics reflects the disease burden in these community clinics, whereas population-based studies provide estimates for a general population that may or may not be accessing the health care system.[10] Understanding the disease burden is important from both perspectives to provide information to investigators, clinicians, patients, and resource allocation stakeholders.

Similar to population-based studies, our study confirmed that allergic comorbidities are also common in children with AD attending community-based primary care clinics. The consistency of our data with other national surveys of allergic diseases lends support that our sample population adequately represents the US AD population. For example, the overall prevalence of asthma found in our sample population of 0 to 5 year olds of 7% closely mirrors the Centers for Disease Control and Prevention statistics from the Behavioral Risk factor Surveillance System 2013 data, which measured the lifetime prevalence of asthma in the general US population to be 7.3% among children under the age of 5.[30] We also confirmed the higher rate of asthma among those with AD (16%) compared to non-AD children (4%) consistent with many previous studies.[31–33] Patients with AD also had a higher prevalence of a family history of allergic disease in our study, confirming that a family history of atopy represents an important risk factor for AD development.

This study provides insight into skin care practices used in the very young—a subject of relatively limited study, especially given our new understanding of the importance of the skin barrier in the development of AD. Kelleher and colleagues[15] found skin barrier function in the first 2 months of life to be the strongest predictors of AD development. Thus, skin care practices that have the potential to alter skin barrier function may represent important determinants or modifiers of AD development. In this study, the majority of caregivers applied some kind of moisturizer on their child's skin, even among children without reported AD diagnosed by a health care provider. As expected, children with AD reported more frequent use of thick moisturizers (ie, creams and ointments) than those without AD, as this is the most common first-line treatment for mild AD. Thus, children with AD seem to receive appropriate education regarding moisturizer use supported by published treatment guidelines.[34] In those without AD, we found the majority of parents used more water-based moisturizers (ie, lotions) on the skin, as opposed to thicker moisturizers, with the majority of usage more than 4 days per week. These skin care practices are similar to those described in a single-center study in Oregon and confirm findings from a market-based study showing a very high use of water-based moisturizers (lotions) in babies on a regular basis.[35,36] This high use of moisturizers is likely a result of cultural preferences or marketing, as skin care guidelines for neonates do not recommend a routine use of moisturizers. The US Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN) released updated guidelines for neonate and infant skin care that state it is unclear whether the routine use of moisturizers benefits infant health.[16] Certain moisturizers could potentially even harm the skin barrier with frequent use, such as those with irritants, fragrances, or high water content,[37–40] thus potentially provoking AD in genetically susceptible neonates. There is no clinical evidence, however, that the use of fragranced lotions in neonates promotes AD. The guidelines do recommend moisturizer use for dry or cracking skin and routine use for AD and infantile seborrheic dermatitis. Published guidelines from a European roundtable meeting on best practice for infants recommend routine moisturizer/moisturized cleanser use during and after bathing for infants who are at high risk of developing AD if it is needed based on their skin condition.[41] It is unclear what influence the frequency and type of moisturizer used has on the development of AD. Further studies are needed to inform best practices in the general population.

Similar to moisturizer use, the type and frequency of bathing is an understudied area in newborn health. Several studies found that exposure to water alone can be detrimental to the skin barrier,[42] although no studies have evaluated the clinical effects of various methods of bathing or frequency on AD development. We found that more than half of the participants received baths/showers on 4 or more days per week. These results are in agreement with a previous case-control study that found the mean frequency of baths children received was 4 to 5 per week.[36] The current AWHONN guidelines for neonates and infants recommended bathing infants every few days and no more than every other day.[16] In addition, AWHONN concluded that there were no clear benefits from daily bathing; however, they left the decision about frequency of bathing to be based on individual neonate's needs considering the family beliefs and culture.[16] Similar recommendations were published in 2009 by the European roundtable meeting on best practice for infants that recommend bathing 2 to 3 times a week by using a mild cleanser and concluded that bathing does not harm the baby.[41]

The strengths of our study include the use of primary care-based sampling to better understand AD burden in the primary care clinical setting, the use of clinics that are members of PBRNs experienced in executing research protocols, and the inclusion of questions regarding skin care practices that are usually overlooked in AD surveys. Limitations of the study are that we cannot exclude the potential for selection bias that could yield artificially inflated prevalence rates. Because of regional variation in AD prevalence, the prevalence data from the states included in this study may not be generalizable to all states in the United States. In addition, the diagnosis of AD was made by parental report of a health care provider diagnosis rather than direct examination by a provider. Last, a possible failure to complete the survey existed for children with more complex health care visits, such as those with chronic health conditions.

In conclusion, our study found a large burden of AD in the primary care practice setting in the United States. The majority of households use skincare practices that may be detrimental to the skin barrier of children not diagnosed with AD, such as frequent bathing and the use of watery lotions frequently. Clinical trials will allow us to identify which skin care practices are optimal for reducing the significant burden of AD in the community.