Adverse childhood experiences may influence pediatric skin disease trajectories

Adverse childhood experiences (ACEs) may play a role in the development and course of pediatric skin diseases, but a lack of standardized research limits clinicians' understanding of the relationship, according to a commentary published in Pediatric Dermatology.

Authors reviewed available evidence connecting ACEs with dermatologic disease and outlined research and clinical approaches for incorporating early-life adversity into pediatric dermatology. ACEs include childhood abuse, neglect, and household dysfunction and are intended to capture the cumulative effects of adversity during childhood.

Higher ACE scores have previously been associated with chronic disease and premature death. Proposed mechanisms include changes in stress responses, immune function, and chronic inflammation, pathways that may also be relevant to dermatologic disease.¹

What evidence links adverse childhood experiences to pediatric skin disease?

Direct evidence examining ACEs and dermatologic conditions remains limited. Atopic dermatitis and psoriasis have received the most attention, according to the authors.

A longitudinal birth cohort found that children exposed to more ACEs had greater odds of atopic dermatitis during early childhood. Research involving psoriasis has primarily included adults, with studies reporting greater ACE exposure among patients with psoriasis compared with controls.³

Other dermatologic conditions have generally been studied using broader measures of trauma, psychosocial stress, or social drivers of health rather than formal ACE frameworks. Studies have reported higher rates of childhood or lifetime trauma among patients with chronic urticaria, alopecia areata, and hidradenitis suppurativa. Perceived stress and psychosocial burden have also been associated with characteristics of vitiligo and hidradenitis suppurativa.¹

“What is known is that early adversity is relevant to pediatric dermatology, but what is missing is scope and cohesion,” Hanigan and Coates wrote.

Why could early-life adversity matter in dermatology care?

The authors noted that limited ACE-specific evidence makes it difficult to determine whether cumulative adversity affects disease development, severity, flares, or treatment response. Variations in symptom control or apparent treatment failure could potentially reflect contextual factors in addition to biological differences, although the authors emphasized that these relationships remain speculative.

ACEs also differ from social drivers of health. ACEs describe cumulative interpersonal and developmental adversity during childhood, whereas social drivers include broader environmental and structural conditions that can affect health outcomes, access to care, and treatment adherence.

For pediatricians and dermatologists, considering both areas may provide additional context when evaluating chronic or difficult-to-control skin disease.

How could ACE-informed approaches be incorporated into practice?

The authors called for additional research using standardized ACE measures across pediatric dermatologic conditions. Potential sources include large population data sets, electronic medical records in health systems already conducting ACE screening, and longitudinal pediatric studies that could evaluate relationships between adversity and disease trajectories over time.

However, the authors cautioned that asking children or caregivers about trauma requires systems for addressing identified needs and protecting sensitive information. Screening or discussion should ideally occur when social work, mental health, primary care, or community resources are available.

Rather than recommending universal dermatologist-led ACE screening, the authors proposed collaborative and selective approaches. For children with new-onset, treatment-refractory, or stress-associated disease, clinicians could review existing screening information or use open-ended questions about psychosocial stressors.

“By pairing more cohesive research with thoughtful and selective clinical integration, pediatric dermatology can move toward a more complete understanding of how early-life adversity shapes the course and experience of children living with chronic skin disease,” the authors concluded.

References

1. Hanigan M, Coates SJ. Adverse Childhood Experiences and Pediatric Dermatology: Implications for Care, Equity, and Research. Pediatr Dermatol. 2026;43(4):1001-1005. doi:10.1111/pde.70309

2. Yu J, Patel RA, Haynie DL, et al. Adverse childhood experiences and premature mortality through mid-adulthood: A five-decade prospective study. Lancet Reg Health Am. 2022;15:100349. doi:10.1016/j.lana.2022.100349

3. McKenzie C, Silverberg JI. Association of Adverse Childhood Experiences With Childhood Atopic Dermatitis in the United States. Dermatitis. 2020;31(2):147-152. doi:10.1097/DER.0000000000000550