The Toll of Atopic Dermatitis is More than Skin Deep: Q & A with Harvard Child Psychologist Jennifer LeBovidge, PhD

Atopic dermatitis (AD)is a chronic disease with profound mental health consequences, according to Jennifer LeBovidge, PhD, attending psychologist in the division of immunology at Boston Children's Hospital and assistant professor of psychology in the department of psychiatry at Harvard Medical School. In a recent interview with Patient Care,^© LeBovidge explained that children and adolescents with the condition are at a 5-fold greater risk of depression and anxiety than their peers without AD, due to drains on mental health exerted by persistent itch, sleep disturbances, social stigma, and the unpredictable nature of flare-ups.

Jennifer LeBovidge, PhD

She also discussed the complex interplay of physical and emotional factors, explaining that the stress of managing AD is compounded by biological and psychosocial factors that can worsen both skin symptoms and emotional well-being.

Despite growing awareness, mental health concerns often go unaddressed in clinical settings, leaving patients and families psychologically isolated. In this interview, LeBovidge stresses the need for a holistic approach to care—one that acknowledges both the visible and invisible burdens of the disease.

Patient Care: I’d like to start with the basics of the connection between atopic dermatitis (AD) and anxiety and depression. Could you provide an overview of prevalence across age groups and the mechanisms that tie them together?

Jennifer LeBovidge, PhD: Absolutely. We know that children and adolescents with AD have about a 1.5-fold increased risk of anxiety and depression compared to those without AD, while adults with AD face an even higher risk—two to three times greater. Several mechanisms contribute to this relationship.

First, having AD is inherently stressful. The intense itch associated with the disease can be difficult to manage, affecting concentration, mood, and sleep. Studies show that 50–80% of children and 30–80% of adults with AD experience sleep disturbances, which may be linked not only to itch but also to circadian rhythms of the skin. Poor sleep can, in turn, negatively impact mood and increase stress levels for both patients and caregivers.

Psychosocial factors also play a role. Patients may feel self-conscious due to visible skin symptoms, face questions from peers, or experience bullying. During flares, they may withdraw from social activities, avoid exercise if sweating worsens their symptoms, and struggle with confidence in managing their condition. The unpredictable nature of flares can lead to a sense of loss of control, further exacerbating stress and affecting adherence to treatment.

On a biological level, psychological stress activates the hypothalamic-pituitary-adrenal (HPA) axis and the sympathetic nervous system, leading to the release of stress hormones that can increase inflammation, worsen AD symptoms, and raise the risk of anxiety and depression. Ultimately, managing AD is a multifactorial challenge—like a soup with many overlapping ingredients.

PC: Given how complex these interactions are, I imagine it’s difficult to pinpoint exactly what’s contributing to a patient’s distress at any given time.

LeBovidge: Exactly. Research often focuses on specific pieces of this puzzle—chronic stress, childhood adversity, or acute daily stressors—but rarely captures the full picture. Clinicians need to consider all these factors and identify opportunities for intervention and support.

PC: Are there specific populations at greater risk for the psychological burden of AD? And does your clinical experience align with the research?

LeBovidge: Yes. Studies show that patients with moderate to severe AD are at higher risk for anxiety and depression, and poorly controlled disease further increases that risk. Encouragingly, improving disease control often alleviates some of these psychological symptoms. However, for many patients, the burden persists even between flares due to underlying mental health conditions and the anticipation of future flare-ups.

Additionally, research suggests that Black, Hispanic, and other non-White patients, as well as those from lower socioeconomic backgrounds, experience higher rates of persistent mental health concerns. These disparities likely stem from broader social determinants of health rather than AD-specific factors alone.

PC: How well do specialists and primary care providers recognize the connection between AD and mental health?

LeBovidge: Many providers are aware of the burden, but addressing it can be challenging. Time constraints in clinical visits and the complexity of AD management—such as individualized skin care routines—often limit discussions about mental health. If providers don’t ask, patients and families may not bring it up due to stigma, a sense that they should be coping better, or simply not realizing that others share their struggles.

Simple, open-ended questions can make a difference. Asking, “What’s the hardest part of managing AD for you?” or “What’s stressful that others might not see?” can encourage meaningful conversations. I also normalize these concerns in my discussions with patients and families, and I often see them nodding in recognition, relieved to know they’re not alone.

PC: What signs should clinicians look for if mental health concerns aren’t openly discussed?

LeBovidge: It’s not always obvious. Red flags include patients who follow an appropriate treatment routine but still experience poor skin control, adherence challenges, or significant distress about their condition. More broadly, clinicians can ask about interest in hobbies, social engagement, and general mood. A decline in these areas may indicate underlying anxiety or depression.

PC: Are there particular screening tools you recommend?

LeBovidge: Yes. Many primary care providers already use validated screeners like the Patient Health Questionnaire (PHQ-9) for depression or its shorter version, the PHQ-2. For anxiety, the Generalized Anxiety Disorder (GAD-7) and GAD-2 are commonly used. These tools don’t provide a diagnosis but can highlight the need for further evaluation and discussion about support options.

PC: Regarding treatment, does symptom relief itself improve mental health, or could medications have direct psychological benefits?

LeBovidge: Both may play a role. Some studies suggest that medications like selective serotonin reuptake inhibitors (SSRIs) might reduce itch, while systemic treatments targeting inflammation could also help alleviate mental health symptoms. But beyond biological mechanisms, better symptom control improves sleep, restores a sense of control, and enhances daily functioning—all of which can boost mood and reduce distress.

PC: What about behavioral interventions? Are there specific therapies that are most effective?

LeBovidge: Cognitive behavioral therapy (CBT) and acceptance and commitment therapy (ACT) are well-established approaches for managing anxiety and depression and are commonly used in patients with chronic conditions. These therapies teach coping strategies, encourage engagement in positive activities, and incorporate relaxation techniques like mindfulness. Mental health providers often tailor these evidence-based interventions to meet the specific needs of patients with AD.

Finding a provider experienced in working with anxiety and depression—ideally with expertise in chronic illness—is key. While experience with AD specifically is a bonus, a provider willing to learn about the condition can still be very effective.

PC: What are some key differences between children and adolescents and adults in mental health burden associated with AD?

LeBovidge: I primarily work with pediatric patients, so I can’t speak as much to adult experiences. However, depression in children may present differently, with more irritability, mood swings, behavioral outbursts, or school refusal. I also want to highlight the significant burden on caregivers. Parents often feel helpless, sleep-deprived, and overwhelmed by time-consuming treatment regimens. This stress can strain the parent-child relationship and contribute to mental health challenges within the entire family unit.

PC: When should a clinician consider referring a child with AD to a mental

LeBovidge: Key indicators include persistent mood changes, withdrawal from activities, changes in sleep or appetite, or difficulties with treatment adherence due to anxiety. Many children with AD develop anticipatory anxiety about treatments, particularly if they’ve had painful experiences in the past. Mental health support can help improve adherence, coping, and overall well-being.

PC: Are there any ongoing research efforts in this area?

LeBovidge: I’m particularly interested in understanding children’s perspectives on AD management and developing psychoeducational resources to support families. There’s a growing awareness that the mental health burden comes from both seen and unseen factors—kids don’t want to stand out due to their condition, but they also want to feel understood. Most existing clinical trials on mental health interventions for AD focus on adults, so we need more research specifically for pediatric patients.