Atopic eczema (AE) is a common childhood skin disease associated with pruritus and sleep disturbance.1 2 3 4 5 Childhood AE can substantially influence quality of life (QOL) among affected children and their parents. The extent of QOL impairment is often correlated with eczema severity, skin dehydration, and staphylococcal infection.6 Additionally, many affected children and their parents develop depression, anxiety, and stress symptoms.1 These mental health issues are correlated with disease severity, impaired QOL, and therapeutic non-compliance.1 7 8 A study using the 42-item Depression, Anxiety, and Stress Scales (DASS-42) found that depression, anxiety, and stress symptoms were present in 21%, 33%, and 23% of Hong Kong adolescent patients with AE, respectively.1 These psychological symptoms were significantly correlated with poor QOL.1 A study of Japanese children showed eczema severity was associated with mental health.9 Furthermore, a retrospective, cross-sectional population-based survey of childhood eczema in the United States revealed that increased eczema severity was associated with a higher risk of mental disorders.10 School-aged children with moderate and severe AE have a higher risk of psychosocial problems that can influence their quality of sleep and cognitive development.11 Emotion, attention, interpersonal relationships, and conduct can also be affected by AE.10 12 Moreover, parents are often unaware of potential psychosocial health issues in their children with eczema.13 Most affected children and their parents do not receive appropriate psychological help and support; they also exhibit low symptom recognition. The impacts of childhood eczema on the parent-child dyad have not been extensively studied in terms of healthrelated quality of life (HRQOL), eczema severity, or mental health status.14

This study was performed to examine associations between mental health issues and disease severity in children or adolescents with AE and their parents using the concise validated 21-item Chinese version of DASS-42 (DASS-21).1 15 16 17

This 2-year cross-sectional survey was conducted between November 2018 and October 2020. Participants with a diagnosis of AE and their parents were recruited at the paediatric dermatology clinic of a university-affiliated hospital in Hong Kong. Eczema was clinically diagnosed in accordance with the United Kingdom Working Party’s Diagnostic Criteria for Atopic Dermatitis.18 Participants and their parents received information about the study including objectives, procedures, voluntary participation, and right of withdrawal. Non-Chinese participants and individuals aged <11 years who were not accompanied by a parent during recruitment were excluded from the study.

The questionnaires were self-administered and supervised by research staff. Parents would help complete the Children’s Dermatology Life Quality Index (CDLQI), Infants’ Dermatitis Quality of Life Index (IDQOL), Nottingham Eczema Severity Score (NESS), and Patient-Oriented Eczema Measure (POEM) for their younger children. The DASS-21 was individually administered to all parents and to children aged >11 years.

The validated Chinese version of the three-item NESS, completed by children aged >11 years or the parents of children aged ≤11 years, was used to determine eczema severity in participating children.19 20 The presence of eczema and number of nights affected by skin itchiness each week in the past 12 months were rated from 1 to 5. A higher score indicated greater eczema severity. Additionally, areas of skin with eczematous lesions (eg, rash, lichenified skin, and/or bleeding) were recorded. Scores on the NESS were categorised as mild (3 to 8), moderate (9 to 11), and severe (12 to 15) eczema. Subjective measurements were determined using the validated seven-item Chinese translation of the POEM, which was also completed by children aged >11 years or the parents of children aged ≤11 years.21 22 Each item was scored from 0 to 4, with a maximum aggregate score of 28. A higher score indicated greater eczema severity in the past week (ranges of 0-2, 3-7, 8-16, 17-24, and 25-28 correspond to clear, mild, moderate, severe, and very severe levels of eczema, respectively).

Health-related QOL was evaluated using the Chinese version of the 10-item CDLQI23 and the 10-item IDQOL.24 The CDLQI was completed by children aged ≥4 years with guidance from parents, whereas the IDQOL was completed by parents of children aged <4 years. Each item on the two scales was scored from 0 to 3, with a maximum aggregate score of 30. A higher score indicated greater eczema-related HRQOL impairment in the past week (CDLQI ranges of 0-1, 2-6, 7-12, 13-18, and 19-30 correspond to no, small, moderate, very large, and extremely large effects on HRQOL, respectively; these ranges for IDQOL are 0-1, 2-5, 6-10, 11-20, and 21-30, respectively).

Mental health was assessed by measuring depression, anxiety, and stress in children with eczema and their parents using the validated Chinese version of the DASS-21. This scale has been used to examine symptoms of depression, anxiety, and stress among individuals with dermatitis or eczema.1 17 The DASS-21 was individually administered to all parents and to children aged >11 years. The DASS-21 composite score can be divided into the DASS Depression, DASS Anxiety, and DASS Stress domains. The total score for each domain ranges from 0 to 42.25 A higher score indicates greater emotional distress in that domain (DASS Depression ranges of 0-9, 10-13, 14-20, 21-27, and ≥28 correspond to normal, mild, moderate, severe, and extremely severe levels, respectively; these ranges for DASS Anxiety are 0-7, 8-9, 10-14, 15-19, and ≥20, whereas they are 0-14, 15-18, 19-25, 26-33, and ≥34 for DASS Stress).

Clinical data were de-identified and analysed using SPSS (Windows version 25.0; IBM Corp, Armonk [NY], United States). Frequency distributions were used to describe the demographic and clinical characteristics of participants. Continuous variables with normal distributions were expressed as means ± standard deviations (corrected to 1 decimal place). Nominal and ordinal variables were expressed in numbers with percentage (corrected to 1 decimal place). Independent samples t tests were used to explore sex differences regarding age, education level, disease severity, QOL, and emotional distress in parents and children. Pearson correlation analysis was utilised to examine associations among mental health, eczema severity, and HRQOL in parents and children of both sexes. Multiple linear regression was performed to adjust for variations in parental and child DASS scores and HRQOL according to demographic and clinical variables. P values <0.05 were considered statistically significant.

Among 380 parents (mean age=41.13±6.52 years), 49 were fathers (mean age=42.50±7.49 years) and 331 were mothers (mean age=40.95±6.36 years). Parents’ education levels were primary to secondary (n=124, 13 males), post-secondary (n=26, 1 male), and undergraduate or above (n=81, 14 males) [Table 1]. Parents reported moderate to extremely severe depression (n=58, 2 males), moderate to extremely severe anxiety (n=101, 5 males), and moderate to extremely severe stress (n=90, 6 males). Parents with a higher education level had lower levels of depression, anxiety, and stress (Fig 1). Compared with fathers, mothers generally had higher overall DASS-21 depression, anxiety, and stress scores (P<0.001-0.005) [Table 1].

Among 432 children (mean age=9.61±5.41 years), 218 were boys (mean age=9.15±5.44 years) and 214 were girls (mean age=10.06±5.35 years). Most children had moderate to severe/very severe disease according to the POEM (n=290) and NESS (n=291). Over half of the children displayed a moderate to extremely large impact on QOL in the CDLQI (n=171, 50.4%) and IDQOL (n=56, 62.9%). Small numbers of children had moderate to extremely severe depression (n=36), anxiety (n=43), and stress (n=30). There were no significant sex differences in disease severity, HRQOL, or emotional distress in the DASS (Table 2).

Disease severity in terms of NESS, POEM, and HRQOL (ie, CDLQI and IDQOL) was generally worse among infants than among older children (Fig 2). Thus, eczema severity and QOL generally appeared to improve with age. Correlation analysis demonstrated that depression, anxiety, and stress levels were significantly associated with NESS, POEM, and CDLQI, regardless of sex (Table 3).

Correlation analysis revealed that eczema severity (NESS and POEM) and HRQOL (CDLQI) were associated with depression, anxiety, and stress levels (DASS-21) among children and parents, regardless of sex (Table 3 and Fig 3). Moreover, depression, anxiety, and stress levels in mothers were significantly correlated with NESS, POEM, IDQOL, and CDLQI. Paternal anxiety and stress levels were correlated with NESS, POEM, and CDLQI (P<0.001 to 0.034). However, paternal depression was only correlated with POEM (P=0.014) [Table 3].

Maternal depression showed a marginal association with higher anxiety levels in boys with eczema (n=42, r=0.311; P=0.045) [Table 3]. However, considering the small number of pairs, no clinical or statistical inferences should be made regarding sex differences in mental health among children and parents. Additionally, there were no statistically significant associations between the mental health of children and parents concerning depression, anxiety, and stress levels in the DASS-21 (Table 3). Regression analysis showed that the child’s HRQOL and parental age mostly explained variation in parental anxiety and stress, whereas parental education level explained variation in parental depression (Table 4). Younger parents had higher risk of developing more anxiety and stress compared with the older parents. Depression level of parents with primary to secondary education was 58% higher than their counterparts with post-secondary education or above. Conversely, the child’s eczema severity and HRQOL mostly explained the child’s emotional distress. Eczema severity and parental emotional distress significantly affected HRQOL in children of all ages (Table 4).

There was no psychological or physiological discomfort resulted from administration of the surveys.

Psychological symptoms of depression, anxiety, and stress were prevalent among children with AE and their parents. Our findings indicate associations between the mental health of children and parents and the eczema severity in those children. Increased eczema severity in children and adolescents led to greater emotional distress in parents and children, regardless of sex. Similarly, psychological symptoms in children and their parents were negatively correlated with the child’s eczema severity (NESS and POEM) and HRQOL impairment (CDLQI or IDQOL), regardless of sex. These strong correlations suggest that psychological symptoms, eczema severity, and impact on QOL have mutually detrimental effects. The DASS depression, anxiety, and stress scores were generally higher among mothers than among fathers, suggesting that mothers (the primary caregivers for children with eczema) were more strongly affected. The present study showed that eczema severity can adversely affect emotions and QOL among parents and children, highlighting the need for further exploration of biopsychosocial interactions among children and adolescents with eczema. Children with severe disease reportedly have more problems with depression and internalising behaviour.26 Behavioural issues can lead to adverse social interactions with peers, further reducing self-esteem and HRQOL. Therefore, interactions among parental perception of the child’s disease severity, the child’s treatment adherence, the child’s social influence by peers, and the child’s school environment should be considered when clinicians make comprehensive decisions about holistic treatments.

Our results using the DASS-21 are consistent with findings in previous studies1 27 that used the more comprehensive DASS-42. As in previous studies,1 27 we found that caregivers were especially likely to experience anxiety related to care provision in the home.28 29 In the present study, maternal depression was associated with a higher anxiety level, particularly in relation to boys with eczema. Accordingly, the Harmonising Outcome Measures for Eczema initiative recommends documentation of disease severity and QOL impairment in eczema cases.25 30 However, there have been few international initiatives and clinical trials regarding the psychological symptoms of caregivers and patients, particularly in the context of childhood eczema. Therefore, we suggest that clinicians should consider these important measurable domains in terms of therapeutic interventions and psychological support. Childhood eczema treatments mainly focus on pharmacological control of physical symptoms, but they often completely neglect the psychological symptoms of affected children and their parents. A more holistic treatment approach is needed for this potentially devastating common childhood disorder. Given the increasing numbers of proposed assessment tools, we advocate a holistic and comprehensive approach for eczema management that considers children and their families. This treatment tool should use a composite score to continuously evaluate disease severity (in objective and subjective manners), QOL impairment, psychological symptoms, and miscellaneous disease surrogates in affected children and their parents.1 16 21 26

A strength of this study was that compared with the DASS-42, the DASS-21 demonstrated better performance with 50% fewer questions and a shorter completion time. Findings from the DASS-21, but not the DASS-42, were correlated with disease severity as measured by the NESS and POEM.1 These discrepancies could have arisen because the sample size in the present study (using the DASS-21) was threefold greater than the sample size in the previous DASS-42 study.1 In the present study, the DASS-21, especially in child and mother, was moderately to strongly correlated with the CDLQI, IDQOL, NESS, and POEM. Thus, the DASS-21 can effectively represent the degree of emotional distress among parents and children or adolescents with eczema. This questionnaire is available in different languages, potentially allowing it to be used for assessment of patients with other ethnicities. To our knowledge, this is the first study to use the DASS-21 to assess the mental health of parents and children with eczema in a paediatric setting. This study revealed the presence of childhood eczema-related depression, anxiety, and stress in affected children and their parents.

This study had a few limitations including its relatively small sample size, especially concerning father-child pairs. A greater proportion of mothers participated in this study, which is expected because mothers are the main caregivers for children with eczema; they typically accompany their children during medical consultations. Considering that paediatric dermatological clinics also cater adolescent patients aged ≥16 years, a few participants aged 16 to 19 years completed the CDLQI on their HRQOL; although these participants exceeded the suggested age range of ≤16 years, the overall results were not affected.

Another limitation is that the number of recruited mothers, who are normally regarded as the main child caregiver, much outweighs that of recruited fathers. In addition, compared with fathers, mothers may know their child’s health more and get anxious or depressed as the eczema severity of their child escalates over time. Thus, the difference of the role in childbearing, sample size and the understanding of child’s health may affect the findings in parental-child correlations. It should be cautious when the results regarding parental-child correlations are studied and presented. The CDLQI (n=339) is a questionnaire for children, and the IDQOL (n=89) is for infants. The different numbers of participants who completed each of these questionnaires is consistent with the CDLQI coverage of a broader age range, whereas the IDQOL is only suitable for children aged <4 years. Although maternal depression was correlated with boys with anxiety, it is important to note that statistical significance should not be used to infer that there is a sex difference between parent and child groups in terms of mental health; such an inference would constitute overgeneralisation.

Children with eczema and their parents demonstrated mental health impairment, which was correlated with disease severity. Eczema-induced anxiety, stress, and other mental health issues in affected children and their parents should be considered by healthcare professionals during comprehensive assessments for the treatment of eczema. In addition to primary eczema, possible secondary psychiatric symptoms should be monitored in children with moderate to severe eczema and their parents. Childhood eczema severity and the mental health of affected children and their parents should be simultaneously evaluated to prevent and manage secondary psychological problems.

Concept or design: KL Hon.
Acquisition of data: PH Lam.
Analysis or interpretation of data: PH Lam, P Ip.
Drafting of the manuscript: PH Lam, KL Hon.
Critical revision of the manuscript for important intellectual content: KL Hon, S Loo, MJ Koh, CHY Chan, CK Li, P Ip.

As an editor of the journal, KL Hon was not involved in the peer review process. Other authors have disclosed no conflicts of interest.

The authors thank all children and parents who participated in this research.

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

This research was approved by the Joint Chinese University of Hong Kong–New Territories East Cluster Clinical Research Ethics Committee, Hong Kong (Ref No.: CRE.2018.401). Written informed consent was obtained from participants and parents prior to the research.

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