The Hidden Impact of Cumulative Life Course Impairment (CLCI) in Dermatology: An Overview

Introduction

Skin diseases are the fourth most common cause of nonfatal morbidity, impacting nearly one-third of the global population. Chronic diseases cause substantial burden, and despite their high prevalence, this burden is often underestimated.^1,2

Chronic skin diseases including atopic dermatitis (AD), psoriasis, and hidradenitis suppurativa (HS), notably affect patients' health-related quality of life (HRQoL), including physical health, emotional well-being, and social interactions. Patients with inflammatory skin diseases often suffer from symptoms that contribute to psychological distress, including anxiety and depression, ultimately resulting in cumulative long-term impairment.³ Understanding Cumulative Life Course Impairment (CLCI) is essential to fully grasp the enduring burden of chronic skin diseases and the irreversible impact on patients' lives over time.⁴ 

This article will further discuss the concept of CLCI in dermatology, explore the chronic nature of AD and its impact on patients.

CLCI in Dermatology: What You Need to Know?

Cumulative Life Course Impairment (CLCI) is a theoretical concept that describes the non- reversible burden of chronic skin diseases over time. In some cases, this persistent burden can lead to chronic impairment and missed opportunities resulting in lasting psychosocial and personal damage. Some individuals are less vulnerable to CLCI, while others are more affected by factors such as stigma, physical comorbidities, and psychological comorbidities. Difficulty in coping with these factors increases the patients' risk of vulnerability.⁴

Hypothetical impairment over a patient’s life course⁴

Recognizing these factors is crucial for healthcare professionals to develop comprehensive management strategies aimed at mitigating the long-term effects of chronic skin diseases such as AD.

The Chronic Nature of AD: A Multidimensional Burden

Atopic dermatitis (AD) is a chronic, relapsing condition marked by eczematous lesions and severe pruritus. Although AD often manifests in infancy, affecting approximately 20% of children, it remains highly prevalent in adults, indicating a lifelong disposition.⁵ 

The chronic nature of AD can lead to a continuous cycle of flare-ups and remissions. The atopic comorbidities such as food allergies, asthma, allergic rhinitis, other immune-mediated inflammatory diseases, and non-atopic comorbidities such as metabolic syndrome, cardiovascular complications, osteoporosis, mental health disorders, etc., may develop in patients with severe disease^4-6

The burden of uncontrolled AD may further lead to other factors such as sleep loss, impaired functioning, self-esteem issues, reduced productivity, cardiovascular diseases, poor bone health, financial strain, and loss of opportunities.^23-27

High Disease Burden in Low BSA Involvement

This chronic and relapsing nature of AD underscores the importance of evaluating the disease's impact, even when the Body Surface Area (BSA) involvement is minimal.

Patients with a BSA involvement may experience a high disease burden. 28 The severity of symptoms and their impact on QoL are not solely dependent on the extent of skin involvement but also on the functionality and visibility of the affected areas. ^28,29

Hands and feet constitute ≈8% of BSA affected by AD, and face constitutes ≈4.5% (according to the rule of nines). These areas can lead to significant physical impairments that affect the QoL, causing psychological distress and disrupting work and school productivity.^29-34 

Over time, these ongoing challenges can contribute to CLCI, highlighting the long-term, cumulative burden of chronic skin diseases.³ 

Timely intervention and escalation of therapy for patients with uncontrolled moderate to severe AD can be critical in helping to manage the signs, symptoms and quality of life impacts of uncontrolled AD. ²⁷

The graph is a model of CLCI throughout the course of AD, adapted from 
Kimball, et al. J Eur Acad Dermatol Venereol. 201027 and Bieber T, et al. Nat Rev Drug Discov. 2023.35

Conclusion

Cumulative Life Course Impairment (CLCI) is a crucial concept in understanding the long-term impact of chronic skin conditions like AD. ^3,4 

For patients with moderate-to-severe AD, the burden extends beyond the skin, causing psychological and social distress, and affecting the overall  QoL.^29-31

Timely and appropriate escalation for patients suffering with uncontrolled AD may help reduce the burdens they face.³⁶

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Cumulative Life Course Impairment in AD: Beyond Skin Symptoms