Impact of the COVID-19 pandemic on adults with moderate-to-severe atopic dermatitis in the Dutch general population

To the Editor: The COVID-19 pandemic might disproportionately impact patients with atopic dermatitis (AD), a chronic inflammatory disorder with immune dysregulation. We conducted a large cross-sectional study to investigate the associations between COVID-19-related impact and AD severity among adults in the Dutch general population. This study was conducted within the Lifelines Cohort Study, a multidisciplinary prospective population-based cohort study examining the health and health-related behaviors of 169,729 persons living in the north of the Netherlands in a unique threegeneration design. All procedures were approved by the medical ethics committee, and all participants provided written informed consent. AD-related data were collected by sending out a digital questionnaire to all adult participants of the Lifelines Cohort Study (N 1⁄4 135,950) between February and May 2020 (response rate, 42.4%). Definitions of AD have been described previously. COVID-19-related variables were collected by sending out a series of COVID-19 questionnaires (weekly between March and May 2020, biweekly until July 2020, and then at monthly intervals until July 2021) to the adult participant of the Lifelines Cohort Study (N1⁄4 139,735), of those 76,377 (54.7%) responded to at least one questionnaire. The selection of COVID-19 questionnaires varied across outcome measures of COVID-19-related variables. The COVID-19 infection rate, COVID-19 vaccination coverage, and side effects were based on combined answers from all available questionnaires; lung disease, body mass index, smoking habits, and information regarding precautions taken, were collected from the first COVID-19 questionnaire, which was sent out at the same period of AD questionnaire. Quality of health care was collected from the 15th questionnaire, while COVID-19-related psychological impact was collected from the 2nd questionnaire, because only these 2 questionnaires included all the variables related to health care and psychological impact, respectively. Associations between AD severity and COVID-19-related impact were analyzed using binary logistic regression models.


RESEARCH LETTER
Impact of the COVID-19 pandemic on adults with moderate-to-severe atopic dermatitis in the Dutch general population To the Editor: The COVID-19 pandemic might disproportionately impact patients with atopic dermatitis (AD), a chronic inflammatory disorder with immune dysregulation. We conducted a large cross-sectional study to investigate the associations between COVID-19-related impact and AD severity among adults in the Dutch general population.
This study was conducted within the Lifelines Cohort Study, 1 a multidisciplinary prospective population-based cohort study examining the health and health-related behaviors of 169,729 persons living in the north of the Netherlands in a unique threegeneration design. All procedures were approved by the medical ethics committee, and all participants provided written informed consent. AD-related data were collected by sending out a digital questionnaire to all adult participants of the Lifelines Cohort Study (N ¼ 135,950) between February and May 2020 (response rate, 42.4%). 2 Definitions of AD have been described previously. 2 COVID-19-related variables were collected by sending out a series of COVID-19 questionnaires (weekly between March and May 2020, biweekly until July 2020, and then at monthly intervals until July 2021) to the adult participant of the Lifelines Cohort Study (N ¼ 139,735), 3 of those 76,377 (54.7%) responded to at least one questionnaire. The selection of COVID-19 questionnaires varied across outcome measures of COVID-19-related variables. The COVID-19 infection rate, COVID-19 vaccination coverage, and side effects were based on combined answers from all available questionnaires; lung disease, body mass index, smoking habits, and information regarding precautions taken, were collected from the first COVID-19 questionnaire, which was sent out at the same period of AD questionnaire. Quality of health care was collected from the 15th questionnaire, while COVID-19-related psychological impact was collected from the 2nd questionnaire, because only these 2 questionnaires included all the variables related to health care and psychological impact, respectively. Associations between AD severity and COVID-19-related impact were analyzed using binary logistic regression models.
A total of 53,545 participants, who responded to at least 1 COVID-19 questionnaire and responded to the AD questionnaire, were included (Table I).
Our finding of no association between COVID-19 infection rate and the presence of AD in adults is consistent with a recent US study where patients with AD, even those treated with immunomodulatory medications, did not have a significantly elevated risk for COVID-19 infection. 4 However, COVID-19-related worries were more often seen in patients with moderate-to-severe AD, which might lead patients to practice more precautions in addition to basic rules (eg, hand hygiene, social y Determined as the proportion of the participants with self-reported physician-diagnosed AD in a lifetime who had current eczema. z According to the patient-oriented eczema measure, among the participants with self-reported physician-diagnosed AD in lifetime.   AD, Atopic dermatitis; OR, odds ratio; COPD, chronic obstructive pulmonary disease; BMI, body mass index. *All characteristics are self-reported. Statistical significance is in bold. If a group size was below 10, we took the following three performances to prevent traceability to particpants: 1) n \10 rather than exact number, was displayed; 2) n \10 was treated as n ¼ 10 when calculating the percentage; and 3) the corresponding number of missing was rounded. y Based on self-reported physician-diagnosed AD in a lifetime. z Adjusted for age, sex, lung disease, smoking, and BMI.
x Defined as receiving either a positive SARS-CoV-2 polymerase chain reaction test or a positive clinician's diagnosis. distance). Furthermore, patients with moderate-tosevere AD tend to encounter dilemmas when comparing the benefit and the potential side effects of COVID-19 vaccines, which may explain why they had comparable vaccination rates to healthy controls. Notably, patients with AD were less likely to search for medical help, reflecting that they did not want to further burden the health care system. Nonetheless, this might also lead to situations where patients miss safety assessments and/or discontinue their treatment, resulting in disease exacerbation, which has been reported in a Danish surveyed-based study. 5 To summarize, the COVID-19 pandemic has a considerable impact on patients with moderate-tosevere AD, highlighting the need for more attention for their overall wellbeing in daily practice.