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ORIGINAL RESEARCH
Atopic Dermatitis and Patient Perspectives:
Insights of Bullying at School and Career
Discrimination at Work
Luca Stingeni
1
Anna Belloni Fortina
2
Ilaria Baiardini
3,4
Katharina Hansel
1
Devis Moretti
5
Filippo Cipriani
5
1
Dermatology Section, Department of
Medicine and Surgery, University of Perugia,
Perugia, Italy;
2
Unit of Dermatology,
Department of Medicine - DIMED,
University of Padua, Padua, Italy;
3
Respiratory Unit for Continuity of Care,
IRCCS, Ospedale Policlinico San Martino,
Genova, Italy;
4
Personalized Medicine
Asthma, & Allergy Clinic, IRCCS Humanitas
Research Hospital, Rozzano, Milan, Italy;
5
Sano Genzyme, Sano S.r.l., Milan, Italy
Background: Atopic dermatitis (AD) is a chronic inammatory skin disease characterized
by recurrent eczematous lesions and intense pruritus. AD patients are known to face
a considerable disease burden, including physical and emotional limitations. There is still
limited knowledge about daily implications in education and occupation. We describe disease
social stigmatization by measuring bullying and self-isolation in students and professional
discrimination in workers. Overall loss of productivity, either at school and at the workplace,
was quantied as the sum of absenteeism (number of days AD sick leave) and presenteeism
(number of days with decreased focus and functionality).
Methods: An on-line web survey was sent to 3235 random recipients and 401 met the
inclusion criteria (self-reporting AD and ≥12 yo). The survey domains included daily
limitations, QoL, feelings and relationships, together with specic questions about bullying,
discrimination and loss of productivity.
Results: AD negatively affected QoL in 51.6% of respondents, whereas 68.8%
considered AD as a real limit to daily routine. More in detail, 39.3% of students were
victims of bullying and 33.9% of workers felt discriminated because of AD. On average,
absenteeism in students was for 17.1 days/year (presenteeism: 19.5 days/year), whereas in
workers, the estimate was 10.9 days/year (presenteeism: 13.1 days/year). Absenteeism and
presenteeism were more pronounced in bullied/discriminated subjects.
Conclusion: AD multidimensional implications deeply affect and undermine personal and
professional fulllments. Our results contribute to a better understanding of what living
with AD means.
Keywords: atopic dermatitis, discrimination, absenteeism, presenteeism
Introduction
Atopic dermatitis (AD) is a chronic, multifactorial inammatory skin disease
characterized by recurrent eczematous lesions and intense pruritus and affecting
up to 20% of children and 8% of adults in Western countries.
1,2
In children, disease
onset occurs in 60% of cases prior to 1 year of age,
3
without difference between
genders,
4
with patients continuing to suffer from AD in adulthood; on the other
hand, more than 20% of adult AD patients suffer from “adult-onset” AD.
5
Recently, lichenied and exudative exural dermatitis, sometimes in combina-
tion with portrait dermatitis, was reported more frequently in childhood onset AD,
whereas prurigo nodularis-like and nummular eczema–like phenotypes in adult
onset AD.
6
Emotional burden of AD is widely documented with consequences on
Correspondence: Anna Belloni Fortina
Unit of Dermatology, Department of
Medicine – DIMED, University of Padua,
Via Gallucci, 4, Padova, 35128, Italy
Email anna.bellonifortina@unipd.it
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Accepted: 5 July 2021
Published: 21 July 2021
the psychological well-being of patients, in analogy with
other chronic skin diseases.
7
AD children might develop
emotional difculties more frequently than kids with dia-
betes or asthma, and emotional-relational disorders com-
prise low self-esteem, behavioral and attachment disorders
and socialization difculties.
8,9
Irritability and inattention
are mainly caused by sleep loss because of frequent and
severe itching with a risk of depression, anxiety, attention
decit hyperactivity disorder, and conduct disorders in
children and adolescents.
10,11
Furthermore, a decrease in
quality of life (QoL) is linked to the association between
sleep loss and depression.
12
Disease severity is a barrier for peer-to-peer relations:
kids with severe AD have fewer friends during primary
and secondary school than those with moderate AD, and
less often belong to a sport club but, in parallel, they tend
to spend more time alone.
13
School performance can be
undermined as a result of missed schooldays, particularly
in adolescents, with repercussions on future
achievements.
14
AD adolescents also present severe dif-
culties in interpersonal relationships.
15
In relational context, bullying is also described,
16
with
an estimated range from 10% to 60%.
17,18
This variability
is based on differences in the denition of bullying itself
(generally described as a repetitive verbal, physical or
social abuse), in the methodology (eg the inclusion of
cyber-bullying), as well as in cultural and social back-
ground. However, it seems that bullying is consistently
more pronounced in adolescents and in severe AD
patients.
19
Moving into adulthood, AD continues to nega-
tively affect sleep and QoL. Adults with AD present
a predisposition to develop depression and anxiety.
20,21
AD can cause considerable working impairment, as
a contribution to both sick leave and lower work
efciency. AD patients experience higher rates of absen-
teeism, and reduced productivity levels (presenteeism)
rates compared to non-AD controls.
14,22
In a recent cross-
sectional survey, AD severity was positively associated
with more sick leave and greater loss of productivity.
23
Finally, AD also compromises the ability to undertake
some specic jobs, such as front ofce positions, or
tasks, such as using irritating chemicals.
24
Recently, Italian dermatologists have worked inten-
sively on the harmonization of AD diagnosis and manage-
ment in adults
25
and in adolescents
26
with great emphasis
on social isolation, bullying and reduced level of attention
at school. Since no recent data were available, to better
explore these aspects, in this study we aimed to
investigate AD QoL, feelings and interpersonal relation-
ships across adolescence and adulthood both at school and
at the workplace, inquiring about the frequency of bullying
and self-isolation episodes among students and profes-
sional discrimination among workers.
Materials and Methods
Patients Enrollment and Characteristics
The survey sample was sourced from Doxa Population
Panel, a proprietary quality-checked database representa-
tive of the Italian population from a socio-demographic
point of view. An on-line questionnaire was randomly sent
by email to 3235 subjects. Four hundred and one matched
the predened inclusion criteria (age ≥12 and self-
reporting to suffer from AD). The highest representation
was in the South (34.2%), followed by North-West
(25.9%), Center (20.2%) and North-East (19.7%).
The nal sample included 200 youngsters (≤ 24 years
old) and 201 adult (≥ 25 years old) patients. The age
distribution was 12–15 years in 50 (12.5%), 16–18 years
in 48 (12.0%), 19–24 years in 101 (25.2%), 25–34 years in
54 (13.5%), 35–44 years in 55 (13.7%), 45–54 years in 53
(13.2%), >54 years in 40 (9.9%). To specically explore
presenteeism/absenteeism as well as the experience of
self-isolation/bullying at school and discrimination at
work, we identied upfront two further sub-groups: stu-
dents (163, 47.1%) and workers (183, 52.9%). The
remaining 55 patients were unemployed or retired.
Demographic and clinical data are reported in Table 1.
Study Design
An online semi-structured interview (CAWI: Computer
Assisted Web Interviewing) with a script-based technique
was used for the study. The survey domains were based on
literature review and 7 deep-dive ethnographic interviews
(Table S1).
The CAWI script, approximately 20 minutes long,
included open questions, 5-point Likert-scale questions,
multiple-choice questions, closed questions (yes/no), and
evaluation scale questions (e.g. 1 to 10). QoL has been
investigated as feelings, stress and stigmatization. Impact
of AD at school has been measured as relational dif-
culty with peers, bullying and self-isolation behaviors.
Questions about bullying were neither direct nor explicit.
In analogy, the impact at work has been investigated in
the dimensions of relational difculty and limitations
that AD causes in work activities and overall job career.
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Presenteeism and absenteeism were measured as the
number of days missed and with decreased productivity.
Overall work/study impairment was considered as the
sum of presenteeism and absenteeism. Internal consis-
tency of the questions for students and for workers has
been evaluated using Cronbach’s alpha coefcient (0.920
and 0.976, respectively).
All comparisons between age groups were decided
upfront.
The χ
2
test with Yates’ continuity correction and
Fisher’s exact test were used to analyse categorical vari-
ables. Statistical analysis was performed using Diana soft-
ware version 2.06.019 (NIPO, Amsterdam, The
Netherlands). In all analyses, a two-sided P value ≤ 0.05
was considered to be signicant.
Informed consent was provided by all patients enrolled
in the study. In the case of minor participants, a parent
provided consent and was also present during the survey.
Results
In 90.8% of cases AD was localized in visible areas:
hands, arms and scalp were the most quoted localiza-
tions. More than 50% of the body surface area (BSA)
was affected by AD in 17.5% of patients. Among signs
and symptoms, itch was by far the most frequent
(87.3%), followed by dry (76.1%) and rough skin
(73.8%), cutaneous rash (67.3%), and pain (46.9%).
Not surprisingly, itch was the most difcult symptom
to cope with (55.7%), followed by pain (26.1%) and
bleedings (24.3%).
Table 1 Demographic and Clinical Data of Atopic Dermatitis Patients
No. Patients (%) No. Patients 401 No. Patients 346*
Youngsters 200 (49.9) Adults 201 (50.1) Students 163 (47.1) Workers 183 (52.9)
Mean age (SD) 18.3 (±3.9) 43.7 (±11.5) 17.9 (±4.0) 39.6 (±12.3)
Females (%) 112 (56.0) 132 (65.7) 86 (52.8) 113 (61.7)
Males (%) 88 (44.0) 69 (34.3) 77 (47.2) 70 (38.3)
AD diagnosis: meantime (SD) 10.2 (±5.1) 14.7 (±11.8) 12.1 (±7.3) 21.1 (±15.4)
Itch presence (%) 184 (92.0) 166 (82.6) 153 (93.9) 146 (79.8)
Itch intensity° (%)
From 8 to 10 64 (32.0) 66 (32.9) 49 (30.1) 61 (33.4)
From 6 to 7 98 (49.0) 91 (45.3) 84 (51.5) 81 (44.2)
From 0 to 5 38 (19.0) 44 (21.9) 30 (18.4) 41 (22.4)
Itch frequency° (%)
From 8 to 10 71 (35.5) 69 (34.4) 54 (33.1) 55 (30.1)
From 6 to 7 95 (47.5) 94 (46.7) 84 (51.5) 89 (48.6)
From 0 to 5 34 (17.0) 38 (18.9) 25 (15.4) 39 (21.3)
AD treated patients
§
189 (94.5) 180 (89.6) 141 (86.5) 1129 (70.5)
AD treatments (%)
Corticosteroids** 86 (43.0) 38 (18.9) 74 (45.4) 38 (20.8)
Topical non 136 (68.0) 74 (36.8) 122 (74.9) 63 (34.4)
Corticosteroid drugs
Antihistamines 79 (39.5) 56 (27.8) 69 (42.3) 53 (29.0)
Immunosuppressant 16 (8.0) 22 (11.0) 9 (5.5) 25 (13.7)
Drugs
Biological drugs 5 (2.5) 12 (6.0) 2 (1.2) 14 (7.7)
Notes: *The remaining 55 patients were unemployed or retired; °scale from 0 to 10; §at least 1 atopic dermatitis drug during the past 1 year; **Topical or oral.
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QoL, Daily Limitations, Feelings, and
Relationships
In everyday life, 51.6% of AD patients reported a reduced
QoL, whereas 68.8% considered AD as a real limit to daily
routine (Figure 1A and B). Both perceptions were statisti-
cally more frequent among students (61.3% and 77.9%,
p<0.05). Embarrassment (41.9%), impotence (39.1%) and
frustration (29.9%) were overall the most quoted feelings
associated with AD (Figure 1C).
AD had an impact, especially in early adolescence
and early adulthood. The 12–15 age group reported an
even higher impact on the QoL (p<0.05), together with
experiences of embarrassment (p<0.05), impotence
(p<0.05) relational avoidance (p<0.05) and disparity
(p<0.05). Furthermore, 92.0% experienced limitations
in daily routine (p<0.05), particularly on sports and
free time activities (p<0.05), social relationships
(p<0.05), perception on general state of health
(p<0.05). Finally, the 12–15 year-group more often
reported stress related to AD signs and symptoms
(p<0.05), that in return negatively affected the pathology
(p<0.05) in a vicious circle.
In early adulthood (25–34 age group), patients more
often experienced a sense of frustration linked to the
pathology (p<0.05), difculties in relationship with partner
(p<0.05) and family members (p<0.05) (Figure 1D).
Bullying and Self-Isolation
AD students were frequently targeted with nicknames
(31.3%) and jokes (30.1%) by classmates who were also
excluding/isolating (22.1%) or being bossy (22.1%) with
them. Overall, 39.3% has experienced at least few epi-
sodes of direct bullying at school in the previous year
(Figure 2A). 65.6% referred self-isolation behaviors;
51.5% found too complex to interact with classmates of
the opposite sex, 44.2% avoided parties, 42.3% gave up
on other school activities and 28.8% missed schooldays in
order to avoid potential bullying situations (Figure 2B).
Self-isolation was more frequent in presence than in
absence of bullying (96.9% vs 45.5%; p<0.05).
Altogether 66.9% have experienced at least one episode
of direct bullying or self-isolation (Figure 2C) related
to AD in the previous year (63.5% in the previous
month). Bullying or self-isolation was more frequent in
males (76.6%; p<0.05) and in the 12–15 age-group
AD negatively
effects my QoL
44.3%
W 12-15
80.0%*61.3%*
S
68.8%
AD limits my
daily routine
60.1%
W 12-15
92.0%*77.9%*
S35-44
36.4%
35-44
49.1%
51.6%
AD makes me
feel:
…Embarrassed
…Impotent
…Frustrated
41.9%
40.4%
W
44.2%
S
60.0%*
12-15
39.1%
56.0%*
46.0%
S 12-15
33.9%
W
20.8%
S
23.5% 44.4%*23.3%
25-34
W
32.8%
27.3%
29.9%
55+
35-44
19-24 …Family,
relatives
…Partner,
boyfriend,
girlfriend
AD worsens
relationship with:
…Friends,
colleagues,
schoolmates
W
32.6% 60.0%*
41.0%
12-15
S
14.6% 38.9%*
25.8%
25-34
S
6.5% 27.8%*13.5%
25-34
12-15
S
42.3%
W
27.3%
W
18.6%
16.0%
27.2%
41.4%
55+
16-18
BA
CD
Figure 1 Quality of life, daily limitations, feelings and relationships.
Notes: Questions were asked specically about AD social consequences such as effect on QoL perception (panel A), limitation in daily activities (pane B), feelings (panel C)
and interpersonal relationships (panel D). The diamond refers to all population (401). Boxes refer to age groups. QoL pooled answers 5/4 in a 1 (“not at all”) to 5 (“highly”)
scale. Feelings refer to pooled answers “always”/“often” in the past 4 weeks. Relationships refer to pooled answers “very much”/“enough”. *Statistically signicant (p≤0.05)
Abbreviations: W, workers (183); S, students (163).
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(88.0%; p<0.05). This latter group reported more rela-
tional difculties with the opposite sex (68.0%; p<0.05),
and more renounces (avoiding parties: 60.0%, p<0.05;
other school-related events 66.0%; p<0.05).
Interestingly, the memory of bullying remained vivid
even in adulthood (55.2%, all ages). The reminiscence
was signicantly higher in young adults (73.2% in 25–
34 age-group, p<0.05) and faded over time (46.0% in 55
+ year-group).
Absenteeism and Presenteeism at School
When inquired about school attendance and performance
in the last 12 months, 17.2% reported school absences, late
entries or early exits due to AD for “one or more day per
week”, meaning minimum 50 days per year (Figure 3).
28.2% reported absenteeism for “few days every 2 weeks/
a few days a month” (15 to 30 days per year) and 54.6%
for “few days per year”. Overall, we calculated an average
17.1 days of absenteeism per student per year.
Regarding presenteeism, on average the impact was
about 19.5 days per year. More in detail, 20.9% recorded
difculties in keeping focus and concentration at school or
doing homework at home for least “one or more day per
week”. 36.8% declared to experience presenteeism for
“few days every 2 weeks/few days a month”, whereas
the remaining 42.3% had an impaired study performance
for “few days per year”. The overall study impairment was
36.6 days per student per year.
Among all ages, absenteeism was more pronounced in
12–15 year-group adolescents (60.0% at least “few days
a month”). This was coherent with a signicantly higher
presence of itch (98.0% vs 87.3%; p<0.05) and sleep
difculties (66.0% vs 29.7%; p<0.05) within the same
age group.
Association Between Bullying,
Presenteeism/Absenteeism and QoL
We found a positive association between bullying and
presenteeism/absenteeism at school. Bullied students
showed a more pronounced absenteeism (61.5% vs
13.0%; p<0.05) as well as presenteeism (71.6% vs
29.6%; p<0.05). Signicantly higher frequencies of bully-
ing (53.0%, p <0.05), bullying and self-isolation (90.0%,
My schoolmates
are bossy with me
because of AD
S
22.1% 28.0%
12-15
13.9%
19-21
Any AD related
bullying
experience
S
39.3% 52.0%
12-15
18.5%
22+
My schoolmates gives
nicknames linked to AD S
31.3% 40.0%
12-15
18.5%
22+
My schoolmates
laugh at me because
of AD
S
30.1% 42.2%
16-18
14.8%
22+
My schoolmates
isolate/exclude me
because of AD
S
22.1% 28.0%
12-15
14.8%
22+
I avoid to go to school
because of AD
S
28.8% 32.0%
12-15
18.5%
22+
Any AD related
self-isolation
behavior
S
65.6% 88.0%*
12-15
33.3%
22+
I struggle to relate to
peers of opposite sex
because of AD
S
51.5% 68.0%*
12-15
29.6%
22+
I give up parties
because of AD
S
44.2% 60.0%*
12-15
29.6%
22+
I give up school trips
because of AD
S
42.3% 66.0%*
12-15
18.5%
22+
Any bullying experience or
self-isolation behavior due
to AD
22+
33.3%
S
66.9% 88.0%*
12-15M
76.6%*
F
58.0%
AB
C
Figure 2 Bullying and self-isolation at school.
Notes: Students (S: 163) were asked specically about episodes linked to bullying (panel A) or self-isolation (panel B).Overall AD burden bullying or self-isolation is
presented in panel (C). Boxes refer to male (M), females (F) or age groups. Percentages are pulled answers “always”/”often”/”sometimes” and refer to the past 12 months.
*Statistically signicant (p≤0.05).
Abbreviations: F, females; M, males.
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60.7%
66.1%
42.3%
54.6%
22.4%
23.0%
27.6%
17.2%
9.3%
6.5%
9.2%
11.0%
7.6%
4.4%
20.9%
17.2%
Work
Presenteeism
Work
Absenteeism
School
Presenteeism
School
Absenteeism
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Weighted Avg
(days/year)
13.1
10.9
17.1
19.5
Figure 3 Absenteeism and presenteeism at school and at work.
Notes: Absenteeism was calculated as the number of days AD sick leave, whereas presenteeism was the number of days with decreased focus and functionality, either at
school or at work.
My colleagues laugh
at me because of AD
W
12.5% 29.3%
22.4%
25-3455+
My colleagues think
they can take
advantage of me
because of AD
W
10.3% 26.8%*
21.9%
25-34
19-24
AD causes stress and
that makes my job
difficult
W
56.1% 73.2%
62.8%
25-34
35-54
Without AD I could be
more productive
W
29.2% 48.8%
42.6%
25-34
55+
AD will limit my career
development
W
20.9% 51.2%
36.6%
25-34
55+
I have to refuse
some duties/tasks
because of AD
W
24.1% 43.9%
34.4%
25-34
55+
I must renounce to
business trips
because of AD
W25-34
20.8% 39.0%
30.1%
55+
At least one AD effect
on work performance
W
58.3% 75.6%
67.8%
25-34
55+
At least one episode
of work
discrimination
linked to AD
W
20.8% 46.3%
33.9%
25-34
55+
I am not trusted with
some duties/tasks
because of AD
W
20.8% 31.7%
29.0%
25-3455+
BA
C
Figure 4 Work performance and discrimination.
Notes: Workers (W: 183) were asked specically about AD-related professional limitation (panel A). Overall impact on work performance was summarized in panel (B). In
panel (C), alternative situations of AD-related discrimination by employers/colleagues are presented. Boxes refer to age groups. Percentages are pulled answers “always”/
”often”/”sometimes” and refer to the past 12 months. *Statistically signicant (p ≤0.05)
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p<0.05), absenteeism (60.0%, p<0.05) were associated
with low QoL.
Work Performance and Discrimination
Regarding working performance, 42.6% could be more pro-
ductive if not suffering from AD, with 62.8% complaining
that professional stress was a negative factor for AD, 34.4%
and 30.1% had to renounce either some duties or to business
trips, respectively. For 36.6% of workers AD posed an
obstacle for career development (Figure 4A). Overall,
67.8% has experienced negative professional implications
in the previous year due to AD (Figure 4B).
About prejudices at the workplace, 29.0% were not
trusted to perform some duties or tasks. Additionally,
colleagues have been perceived to laugh (22.4%) and to
take advantage of AD workers (21.9%). Overall, in 33.9%
of cases, there was the perception of being victim of at
least one episode of discrimination at work due to AD
(Figure 4C). Only 1 patient out of 2 openly disclosed to
suffer from AD at work. Such attitude was less pro-
nounced in young workers (26.8% in 25–34 year-group
vs 66.7% in 45–54 year-group; p<0.05). Finally, 9.3% did
not get a desired job because of AD.
Absenteeism and Presenteeism at Work
In the previous year, workers reported on average 10.9
days of absence because of AD. More specically 4.4% of
workers declared absence, late entries or early exits for
“one or more day per week” and 29.5% for “few days
every 2 weeks/a few days per month”. The residual 66.1%
referred absenteeism for “few days per year”. Each worker
also declared on average 13.1 days of impaired productiv-
ity. 60.7% experienced presenteeism for “few days
per year”, 31.7% for 15 to 30 days a year, whereas 7.6%
for at least 50 days per year. The overall work impairment
(the aggregate of absenteeism and presenteeism) was 24.0
days per worker per year.
Interestingly, 78.9% (p<0.05) of workers who have
been absent or not very productive because of AD recalled
having been bullied at school and 68.4% (p<0.05) reported
a concomitant experience of discrimination at work.
Association Between Professional
Discrimination, Presenteeism/
Absenteeism and QoL
In analogy with bullied students, discriminated workers
reported a more pronounced absenteeism (67.7% vs
16.5%; p<0.05) as well as presenteeism (71.0% vs
23.1%; p<0.05) compared to non-discriminated ones.
Signicantly higher frequencies of discrimination
(58.0%, p <0.05), absenteeism (55.6%, p<0.05), and pre-
senteeism (64.2%, p<0.05) were found in workers report-
ing low QoL.
Discussion
This study on patient-reported AD burden in Italy explores
the educational and working context, providing novel
insights, in both youngsters and adults.
Our analysis shows a signicant negative impact of AD
on self-condence and daily choices. Embarrassment,
impotence and frustration are the most quoted feelings
associated with AD. Such feelings might explain the
reported difculties in establishing and maintaining rela-
tionships with family members, partners and friends, as
well as schoolmates and colleagues. One patient out of 2
has a perception of impaired QoL. Such feeling is more
frequently reported by students (6 out of 10) and particu-
larly in those 12–15-year-old (8 out of 10). 68.8% of
all AD patients consider AD as a real limit to daily life
(sport, free activities), particularly youngest teenagers
(92.0%). AD negatively undermines emotional well-
being, contributing to social stigma and susceptibility to
stress. Our data are in line with a recent European study on
1189 adult AD patients, in which 55.0% reported
a moderate to extremely large impairment in quality of
life and 88.0% of patients with severe AD reported
a compromised ability to face life.
24
In this study, we
documented the distress at school and in the occupational
environment by deep diving into students and workers.
Among students, 39.2% feel bullied because of AD,
whereas 33.9% of workers recall one or more episodes
of AD-related professional discrimination, with colleagues
taking advantage or mocking with jokes. We also docu-
ment an association between memories of bullying at
school and current experience of discrimination in the
workplace.
Self-isolation behaviors are also quite frequent with 7
out of 10 students giving up on social activities, such as
attending parties or school trips. Such renounces are more
frequent in the 12–15-year-old subgroup. In addition, in
94.2% of adolescents bullying and self-isolation are both
present, in line with documented relationship between skin
diseases and adverse relational and psychological
sequelae.
16
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These aspects are similar to those referred by workers,
for whom 67.8% reported negative professional implica-
tions, feeling limited in job performance or uncertain
about career achievements and development. One worker
out of 3 is not able to perform specic duties or renounces
to business trips, whereas 42.6% could be more productive
if not suffering from AD, conrming the results of pre-
vious studies on the work life of patients with AD.
27,28
Overall, we estimate a negative effect on 1 of 3 workers,
as recently demonstrated.
24
Recurrent episodes of absenteeism and presenteeism are
present both among students and workers. On average,
students miss 17.1 days of school per year and have 19.5
days per year of impaired focus and concentration.
Absenteeism and presenteeism are all amplied in youngest
students. Six adolescents out of 10 have a negative impact
for few days per month, nearly 30 days/year, in line with
a previous observation (26 days of school lost).
13
In strict
analogy, workers report on average 10.9 days of absence
and 13.1 days of impaired productivity because of AD.
Ring et al recently showed that 25.0% of adult AD patients
missed more than 6 days per year,
24
whereas Andersen et al
reported in severe AD patients up to 0.5 days of absentee-
ism and 19.7 hours of presenteeism per week.
23
Itch can
easily explain the reduced focus on students and productiv-
ity in workers because of poor sleep quality at night and
concentration during the day.
29,30
Involvement of visible
localizations can also undermine patient’s self-condence
and willingness to go to school or work.
Inclusion at school and acceptance in the workplace
should be encouraged in order to guarantee a proper edu-
cation as well as a future job career: up to 38% of AD
patients cannot pursue the desired studies or occupation.
14
Our study also highlights the association between an
unfriendly environment at school/work and poor atten-
dance or performance. In our sample, bullied adolescents
show less attendance and attention compared to not bullied
ones. In parallel, discriminated workers show signicantly
higher rates of absenteeism and presenteeism compared to
included ones and recall being the object of bullying at
school. Despite further studies on a wider population are
needed in order to unequivocally demonstrate a cause-
effect link, this association should not be underestimated.
All our results emphasize that AD impacts especially in
proximity of important life phases, such as early adolescence
(12–15 years) and early adulthood/rst working experiences
(25–34 years). In these transitions, AD seems to constitute an
additional hurdle that fuels personal uncertainty and
insecurity, together with considerable difculties in under-
taking basic social activities. Young adolescents seem the
most fragile, demanding further investigation in order to
better understand and, consequently, to develop specic psy-
cho-educational support interventions,
31
not ignoring the
personal and professional implications in caregivers as well
as in siblings of AD patients.
The main limitation of our study is typical of patient
surveys and consists in the self-reporting AD diagnosis by
patients. Nevertheless, the enrollment was anonymous,
blinded and responders did not know upfront that we
were investigating AD since the screening questions also
included other common diseases. Anonymization pre-
vented us from re-contacting and asking for additional
information. We are condent about the consistency of
the nal population because all signs and symptoms,
including disease localizations, pharmacological treat-
ments and comorbidities, are compatible with AD.
Moreover, given that participants were self-reporting AD
diagnosis, disease severity was not considered in our
study. However, this is not necessarily a limitation
because the survey aimed to represent the general picture
of AD patients. In addition to memories of bullying in
adults, all questions refer to the last month or last year, in
order to minimize any recall bias, another possible short-
coming of retrospective studies. Finally, our interest was
understanding AD impact on patient daily experience with
specic impact on studying and working. Our survey was
tailored specically on AD, not including matched control
groups without AD or with other chronic skin diseases,
but the exploratory nature of our work will hopefully draw
further attention to the topic and encourage future studies.
In conclusion, this study is the rst attempt in Italy to
address the relevance of deep understanding of bullying at
school and career discrimination at work in adolescent and
adult AD patients. AD impacts transversely various aspects
such as education and professional fullment and AD
patients can encounter prejudice, ignorance or misunder-
standing about their condition. Knowledge of these aspects
could be the rst step in relieving the burden of disease.
Statement of Compliance
All procedures were in accordance with both international
(ESOMAR and EphMRA) and national (FarmIndustria)
ethical standards as well as with the 1964 Helsinki
Declaration, its later amendments or comparable ethical
standards. The survey did not require ethics approval from
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IRB/local ethics committee. Informed consent was obtained
from all individual participants involved in the present study.
Acknowledgments
Interviews and statistical analysis performed by
DOXApharma, funded by Sano S.r.l. Medical writing
and editorial support provided by Antonella Demma,
funded by Sano S.r.l.
Author Contributions
All authors made substantial contributions to conception
and design, acquisition of data, or analysis and interpreta-
tion of data; took part in drafting the article or revising it
critically for important intellectual content; agreed to sub-
mit to the current journal; gave nal approval of the
version to be published; and agreed to be accountable for
all aspects of the work.
Funding
Research sponsored by Sano S.r.l.
Disclosure
L. Stingeni has served on advisory boards and received hon-
oraria for lectures from AbbVie, Almirall, Celgene, Eli Lilly,
Novartis, Sano Genzyme. A. Belloni Fortina has served on
advisory boards from AbbVie, Galderma, Celgene, Eli Lilly,
Novartis, Sano Genzyme. K. Hansel has served on advisory
boards and received honoraria for lectures from AbbVie and
Celgene. I. Baiardini IB reports scientic consultations and/or
lectures from Boehringer Ingelheim, Chiesi Farmaceutici,
GlaxoSmithKline, Menarini, Novartis, Sano Genzyme,
Biofutura, Mundifarma, AstraZeneca. D. Moretti and
F. Cipriani are Sano employees, may hold stock and/or
stock options at the company.
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