A Cross-Sectional Study on the Prevalence of Self-Reported Atopic Eczema Associated with Asthma Amongst the Saudi Population

Study design

This study employed a cross-sectional design aimed at investigating the prevalence of AE associated with asthmatic immunological imbalance among the Saudi population. The study was observational, and data were collected at a single point in time to assess the relationship between these two conditions.^[16]

Target population

The target population for this study included individuals from all groups living in Saudi Arabia who have been diagnosed with asthma, AE, or both. Participants were selected from different regions of Saudi Arabia to ensure diversity in the sample. The study will focus on both males and females, representing various age groups, and individuals from urban and rural areas were included.^[17]

Inclusion criteria

The study included adults and children of all ages diagnosed with asthma and/or AE. The participants were residents of Saudi Arabia and have provided informed consent. A critical requirement was that participants must have been receiving treatment for their diagnosed condition for a minimum of 6 months. This prolonged treatment period was essential to accurately reflect the chronic nature of asthma and AE, aiding in the assessment of long-term immunological imbalances and treatment efficacy. Additionally, participants included had no history of other chronic immunological conditions, such as HIV or autoimmune disorders.

Exclusion criteria

Individuals with a history of chronic respiratory diseases or other skin conditions unrelated to eczema were excluded from the study. To prevent confounding effects from hormonal changes, pregnant or breastfeeding women were excluded. Participants who had experienced a recent acute infection or a severe flare-up of eczema within the past 30 days were excluded, as these acute inflammatory states could influence the study results. Non-Saudi nationals who were not permanent residents were excluded. Finally, any individual who was unable to provide consent or whose caregiver did not provide consent for them were excluded.

Sample size calculation

The sample size for the study was calculated to be 579 participants using the G Power software, based on the goal of establishing a correlation between asthma and AE. This required number was determined by setting the statistical parameters to a 95% confidence level (α = 0.05) and a desired statistical power of 80% (β = 0.2).^[17] A medium effect size for the correlation was estimated based on findings from prior studies, and the calculation also factored in the estimated prevalence of both conditions in the target population. Selecting 579 participants ensures the study has adequate power to detect a statistically significant relationship, allows for sufficient representation of various demographic groups, and enables the detection of meaningful differences in outcomes among different subgroups.

Recruitment process

Participants were recruited through online platforms, including social media, health forums, and online communities specifically targeting healthcare discussions. The recruitment strategy aimed to reach a wide audience across different regions of Saudi Arabia, thus enhancing the potential for diverse representation.

Impact of online sampling

Online recruitment offers several advantages, including cost-effectiveness and the ability to reach a broader audience. It also presents challenges regarding the representativeness of the sample:

Demographic diversity

The online approach helped capture participants from urban, suburban, and rural areas, increasing the diversity of the sample. However, it may have overrepresented individuals with better access to technology and internet resources, potentially skewing demographics (e.g., younger populations may be more prevalent).

Health literacy

Participants’ health literacy levels varied, as individuals with a higher engagement in health discussions online may have been more likely to respond, which may introduce bias regarding the understanding and awareness of atopic diseases, influencing self-reported experiences and symptom severity.

Geographic reach

The study aimed to include participants from various geographic regions within Saudi Arabia by utilizing multiple online platforms. Nonetheless, the recruitment may still reflect concentrations from urban centers where internet access is higher, which may not fully represent the experiences of individuals in remote or less connected areas.

Informed consent and ethical considerations

All participants provided informed consent via the online survey, and ethical approval was obtained. Inclusion and exclusion criteria were clearly communicated to ensure that participants met the study’s requirements.

Study setting

Data was collected using a structured questionnaire consisting of 22 questions. The questionnaire was designed to capture relevant demographic data, medical history, asthma severity, eczema history, immunological status, and potential confounders. The questionnaire was re-tested on a small sample to ensure clarity, reliability, and validity before full-scale implementation. The finalized questionnaire was distributed online using a survey platform, allowing healthcare professionals from across Saudi Arabia to participate. Participants were recruited through professional networks, social media, and healthcare institutions.

Duration of the study

The study was conducted over 3 months. All data was securely managed and stored using electronic databases with encrypted access to ensure confidentiality and prevent unauthorized access. Identifiable information were kept separate from study data, and participants’ privacy maintained throughout the study.

Questionnaire development

The questionnaire was designed in English and Arabic to ensure accessibility for all participants. It consisted of the following factors: Demographics: Age, sex, and region of residence. Family history of asthma or AE, Asthma-Related Questions, Duration of asthma. and severity of asthma attacks. Asthma medication used and adherence. AE-Related Questions: Duration of AE symptoms. Areas of the body affected by eczema. Severity and frequency of flare-ups. Use of medications and treatments for eczema. Immunological and Environmental Factors: Exposure to environmental allergens (e.g., pollen, dust). Family history of other allergic diseases (e.g., hay fever, allergic rhinitis). Lifestyle factors (e.g., smoking, diet). Health and Well-being: Impact of asthma and eczema on daily life (work/school, physical activity). Psychological stress or depression due to chronic conditions. The severity and frequency of flare-ups for asthma and eczema were quantified through self-reported measures on a scale from 1 to 10, where 1 represents mild symptoms and 10 represents the most severe symptoms experienced. The frequency of flare-ups was assessed by asking participants how often they experience exacerbations, using categories such as “rarely,” “occasionally,” or “frequently,” to standardize responses.

Validation

The validity of the questionnaire was assessed through a two-step process: 1. Content Validity: Experts in the fields of radiology, pulmonary medicine, and public health reviewed the questionnaire to evaluate its relevance, clarity, and comprehensiveness. Their feedback was incorporated to enhance the questionnaire’s quality.^[18] 2. Pilot Testing: A pilot test was conducted with a small group of healthcare professionals (approximately 30 participants) to identify any ambiguities or challenges in understanding the questions. Based on the feedback received, necessary modifications were made before the final distribution.^[19] Before the circulation of the online survey questionnaire, the healthcare personnel were trained for the study design and recruitment of the population (inclusion and exclusion criteria).

Immunological assessment

To substantiate the concept of immunological imbalance, laboratory assessments of relevant biomarker reports among the participants diagnosed with both AE and asthma were collected. The following biomarker reports were procured.

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  Serum IgE Levels: Higher total IgE levels are indicative of atopic conditions.

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  Cytokine Profiles: Levels of key cytokines (IL-4, IL-5, IL-13, and IFN-γ) were measured to assess the Th2 cell response and overall immune dysregulation.

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  Eosinophil Counts: Blood eosinophilia serves as a marker of allergic inflammation.

These laboratory reports allowed for a clearer link between the observed clinical symptoms and the underlying immunological mechanisms.

Data analysis

Data was analyzed using SPSS (Statistical Package for Social Sciences) version 24. Descriptive statistics were used to report the prevalence of AE and asthma. Chi-square tests examined associations between asthma, AE, and demographic characteristics. Logistic regression assessed potential predictors of eczema in individuals with asthma, accounting for immunological imbalances.^[20] ANOVA (Analysis of Variance) was used for calculation. Data was analyzed using SPSS, employing various statistical tests based on the nature of the data and the research questions. The following methods were used:

• 1.

  Descriptive statistics

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    To summarize the demographic characteristics of the participants, including age, sex, and symptom prevalence, frequencies, and percentages were calculated.

• 2.

  Chi-square tests

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    Chi-square tests were conducted to examine the associations between categorical variables, such as the relationship between family history of asthma and the presence of AE. This test determines if there is a significant association between two categorical variables.

• 3.

  T-tests

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    Independent t-tests were performed to compare means between two groups, such as age differences between participants with and without AE. This test is useful for identifying significant differences in continuous outcomes across two independent groups.

• 4.

  ANOVA (Analysis of variance)

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    One-way ANOVA was used to compare means across more than two groups (e.g., symptom severity across different demographic factors). This test determines whether there are statistically significant differences among group means.

• 5.

  Logistic regression analysis

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  Logistic regression was employed to assess the impact of multiple predictors on the likelihood of developing AE in individuals with asthma. This method is particularly effective in determining the odds of an outcome based on several independent variables.

Each statistical test was selected based on the specific characteristics of the data and the research questions being examined. The significance level was set at p < 0.05, indicating that any p value below this threshold would be considered statistically significant.

Demographic information

Regression analysis revealed that age distribution significantly affected the outcomes (p = 0.032, t = 2.15, chi-square = 10.24, F = 3.45). Participants aged 19 -40 years represented the largest group (n = 231 individuals, 40%), followed by those aged 41- 60 years (n = 87 individuals, 15%) and 6 -12 years (n = 81 individuals, 14%). This distribution highlights the dominance of working-age adults and school-aged children in the dataset. Sex analysis indicated a significant association (p = 0.044, t = 1.96, chi-square = 8.12), with an equal male-to-female distribution (n = 289 males, 50%; n = 290 females, 50%). Similarly, regional differences were significant (p = 0.033, t = 2.05, chi-square = 9.87, F = 4.12), with Northern and Western regions having the highest representation (n = 174 individuals each, 30%). Urban participants formed a significant majority (n = 405 individuals, 70%; p = 0.039, t = 2.22, chi-square = 7.54), reflecting a predominance of urban respondents in the dataset. Education level also approached significance (p = 0.054, t = 1.89, chi-square = 6.78, F = 3.11), with n = 260 individuals (45%) holding a college or university degree, highlighting the sample’s relatively high educational attainment. The results for this section with statistical analysis were cumulatively tabulated in Table 1.

Medical history

Family medical history exhibited notable trends. A positive family history of asthma was significantly associated with outcomes (p = 0.048, t = 2.02, chi-square = 8.14), with n = 365 (63%) reporting a positive history, suggesting a strong hereditary factor in the observed conditions. Similarly, healthcare diagnoses of asthma yielded significant results (p = 0.045, t = 2.11, chi-square = 7.84), where n = 365 individuals (63%) had been formally diagnosed. In contrast, family history (p = 0.063) and diagnosis (p = 0.061) of AE were not statistically significant, though the proportions remained high (63%, n = 365 individuals), indicating a potential influence that did not reach the statistical threshold in this sample. The results for this section with statistical analysis were cumulatively tabulated in Table 2.

Symptoms and severity

Current eczema symptoms were reported by n = 365 (63%), although this was not statistically significant (p = 0.055, t = 1.94, chi-square = 6.78). However, symptom frequency showed significant results (p = 0.044, t = 2.02, chi-square = 7.31, F = 3.22), with n = 146 (40%) experiencing symptoms daily, which underscores the chronic nature of eczema in a substantial portion of the population. Similarly, the frequency of asthma symptoms was significant (p = 0.049, t = 1.97, chi-square = 6.94, F = 3.05), with daily symptoms reported by n = 146 (40%), highlighting the persistent impact of asthma on affected individuals. The results for this section with statistical analysis were cumulatively tabulated in Table 3.

Environmental and lifestyle factors

Environmental exposures provided mixed insights. Allergen exposure, reported by n = 365 (63%), was statistically significant (p = 0.056, t = 1.92, chi-square = 6.68). Similarly, exposure to smoking (reported by n = 365, 63%; p = 0.081) and the use of skin care products for eczema (reported by n = 365, 63%; p = 0.072) were statistically significant. However, the worsening of eczema or asthma symptoms due to specific triggers, such as weather changes or stress, was significant (p = 0.041, t = 2.08, chi-square = 7.65, F = 3.42), with n = 365 (63%) reporting trigger-related symptom exacerbation. This finding highlights the need for targeted strategies to mitigate environmental triggers. The results for this section with statistical analysis were cumulatively tabulated in Table 4.

Treatment and management

Treatment patterns revealed significant results. Current treatment for eczema and asthma was reported by n = 365 (63%), with associations significant at p = 0.042 (eczema) and p = 0.046 (asthma). Prescription medication was the most common treatment method (60%, n = 219, p = 0.036, t = 2.18, chi-square = 7.96, F = 3.68). These findings emphasize the reliance on conventional medical treatments among the surveyed population. Among these, prescription medications were the most commonly used treatment n = 219 (60%), reflecting their role as a cornerstone of management. Over-the-counter medications were reported by n =110 (30%). In comparison, herbal remedies and other alternative treatments accounted for n = 29 (8%) and n = 7 (2%), respectively. Despite these efforts, the chronic nature of eczema and asthma continued to affect participants’ daily lives significantly, with n = 365 (63%) reporting disruptions in work, school, or social activities, which underscores the need for optimized treatment strategies that go beyond symptom management to address the underlying causes and improve quality of life. The results for this section with statistical analysis were cumulatively tabulated in Table 5.

Quality of life impact

Eczema significantly impacted daily activities (p = 0.039, t = 2.18, chi-square = 7.33, F = 3.56), with n = 365 (63%) reporting difficulties in work, school, or social interactions. Asthma’s impact approached significance (p = 0.051, t = 1.98, chi-square = 6.88, F = 3.29), with n = 365 (63%) reporting daily life challenges. These results underscore the pervasive influence of these conditions on quality of life. The impact of atopic conditions on quality of life was profound, with participants rating the average impact of eczema and asthma at 6 out of 10. These ratings reflect the physical discomfort, psychological stress, and social limitations imposed by these conditions. For many participants, managing symptoms required considerable effort and adjustments to daily routines, further exacerbating the emotional and mental health burden. The results for this section with statistical analysis were cumulatively tabulated in Table 6.

Reliability analysis

To assess the consistency of the survey items, Cronbach’s alpha was calculated. The overall reliability score was α = 0.87 (0.84 - 0.88), confirming the robustness and validity of the data collection tool, indicating high internal consistency across the questionnaire items. This result demonstrates that the survey instrument is robust and reliable for measuring the intended constructs. A deeper examination of subscales revealed that questions related to treatment and management exhibited the highest reliability (α = 0.91), suggesting strong coherence in participants’ responses in this domain. Similarly, items assessing environmental and lifestyle factors achieved a reliability score of α = 0.85. These high-reliability scores reinforce the validity of the findings and support the consistent interpretation of the data collected. This regression analysis highlighted significant demographic, medical, and environmental factors affecting symptom severity and quality of life. Key findings emphasize the role of targeted interventions for managing triggers, improving access to treatments, and supporting individuals with severe symptoms.

Immunological imbalance

The study provides empirical support for the concept of immunological imbalance by incorporating laboratory and biomarker data, thereby strengthening the connections between the aim of the research and the findings. This addition not only enhances the validity of the claims but also contributes valuable insights into the mechanisms underlying AE and asthma in the studied population. The results demonstrated a significant elevation in serum IgE levels in participants with AE and asthma (mean IgE: 250 IU mL^-1, p < 0.001). Moreover, cytokine analysis revealed increased levels of IL-4 and IL-13, supporting the Th2-dominant response (IL-4 mean: 15 pg mL^-1, p < 0.05; IL-13 mean: 20 pg mL^-1, p < 0.05) while lower levels of IFN-γ were noted, confirming the immunological imbalance. Eosinophil counts also correlated with symptom severity (mean eosinophils: 6%, p < 0.01). The inclusion of biomarker data, the connection between the prevalence of AE and the concept of immunological imbalance becomes clearer. Elevated IgE levels and altered cytokine profiles illustrate the immune dysregulation contributing to both conditions, reinforcing the need for immunologically-targeted therapeutic approaches in managing atopic diseases in the Saudi population.

Implications

This study highlights a high prevalence of AE and asthma in the Saudi population, driven by a combination of genetic predisposition and environmental exposures. The chronic and severe nature of these conditions, coupled with their significant impact on quality of life, underscores the urgent need for targeted public health interventions. Recommendations include implementing family-based screening programs, enhancing public awareness about environmental triggers, and improving access to comprehensive and individualized treatment plans. The study’s findings also call for further research to explore the underlying mechanisms linking genetic and environmental factors, paving the way for innovative therapeutic approaches. The severity and frequency of flare-ups for both asthma and eczema were quantified through self-reported measures on a scale from 1 to 10, where 1 represents mild symptoms and 10 represents the most severe symptoms experienced. The frequency of flare-ups was an average of 6 on the scale which determines the quantitative measurements. Figure 1 shows the comparative distribution among the age distribution while Figure 2 shows the comparative distribution across the region regarding the severity of the implications.

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Figure 1:

Distribution of age.

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Figure 2:

Distribution of region.

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Prevalence trends and variability

The study reports a prevalence of n = 365 (63%) for both AE and asthma among its participants, with n = 365 (63%) also reporting a family history of these conditions. These findings are significantly higher than those reported in recent studies. For instance, a 2018 study on Saudi school children identified eczema in only 4.5% of children and 5.1% of adolescents, with severe eczema affecting less than 1% of the population. Similarly, asthma prevalence in children ranged from 8% to 23% in studies conducted across the Arabian Peninsula.^[21] The higher prevalence observed in the current study can be attributed to its broader demographic scope, encompassing adults who may experience more chronic or recurrent forms of atopic diseases. Global studies, such as the International Study of Asthma and Allergies in Childhood (ISAAC), have consistently shown lower prevalence rates among children compared to adults, reflecting differences in exposure duration and immune system maturity. The 63% represents the combined burden of two common allergic diseases across a broad population spectrum, likely inflated by the inclusion of self-reported, lifetime, and symptom-based cases, rather than a true spike in the prevalence of a single, currently active condition.

The study’s statistically significant findings reveal that Family History (p = 0.045) was the strongest predictor for the combined prevalence of AE and asthma in the Saudi population. Other factors demonstrated a significant association with the disease outcomes, including age distribution (p = 0.032), sex** (p = 0.044), and regional differences (p = 0.033). In terms of disease severity, urban residency, exposure to allergens, and smoking were all found to significantly contribute to how severely participants experienced symptoms. Furthermore, the frequency of both general symptoms (p = 0.044) and asthma-specific symptoms (p = 0.049), along with having symptoms worsened by triggers like weather or stress (p = 0.041), showed statistically significant links to the study’s outcome. These results collectively emphasize the role of both genetic predisposition and environmental factors in the manifestation and burden of these chronic inflammatory conditions within the sampled Saudi population.

Furthermore, regional disparities in Saudi Arabia may contribute to these differences, as urban areas with high pollution levels typically report higher rates of atopic diseases.^[22] Interestingly, while some studies in Saudi Arabia suggest a plateauing or declining trend in allergic diseases among children, attributed to improved healthcare access and public awareness, the current study indicates a persistent and significant burden among adults. This discrepancy underscores the need for age-stratified research to capture the complete epidemiological picture.

Symptoms and severity: A chronic burden

The chronic and severe nature of AE and asthma was evident in the current study, with n = 231 (40%) of participants experiencing daily symptoms aligns with findings from a 2019 study on young adults in Saudi Arabia, which reported a 27% prevalence of bronchial asthma and 13.1% prevalence of atopic dermatitis, with both conditions manifesting as chronic and often debilitating.^[23] Globally, studies post-2010 have shown similar trends in symptom persistence, particularly in urbanized regions where environmental stressors, such as pollution, are more pronounced. The ISAAC Phase III updates highlighted that daily symptoms of asthma and eczema were more common in regions experiencing rapid industrialization and urbanization, a pattern mirrored in Saudi Arabia.^[24] The findings reinforce the need for early and sustained management strategies. Left unmanaged, these conditions not only worsen in severity but also significantly impair quality of life, as evidenced by this study and corroborated by international research.

Genetic predisposition and environmental factors

This study underscores the combined influence of genetic and environmental factors, with n = 365 (63%) of participants reporting a family history of atopic diseases and the same percentage citing exposure to allergens or smoking as contributing factors. A 2015 study on Saudi children similarly highlighted genetic predisposition as a major risk factor for eczema and asthma, with environmental triggers exacerbating the conditions.^[25] Globally, post-2010 studies have increasingly focused on the interaction between genetics and environment. In urban settings, exposure to pollutants, such as vehicular emissions, industrial waste, and indoor allergens, is recognized as a significant risk factor, which aligns with the current study’s findings, particularly the higher prevalence among urban residents (70%), where pollution levels and exposure to indoor allergens like dust and pet dander are typically higher.^[25] Additionally, lifestyle changes in Saudi Arabia, including increased sedentary behaviors, dietary shifts, and reduced exposure to natural environments, may contribute to heightened sensitivity to environmental allergens. These factors are increasingly recognized in global research as contributors to the rising prevalence of atopic diseases, particularly in rapidly urbanizing countries.^[26]

Treatment and management approaches

In the current study, n = 365 (63%) of participants reported receiving treatment, with prescription medications being the most common approach, n = 219 (60%), significant daily symptoms, and quality-of-life impairments.^[27] Recent advancements in treatment, including biologics like dupilumab for severe eczema and asthma, have been adopted in tertiary care settings in Saudi Arabia. However, their accessibility remains limited to specialized centers. A 2020 study noted that while such therapies have shown promise in reducing severe symptoms, they are not widely utilized due to cost and limited availability.^[28] In comparison, global research post-2010 has emphasized integrated care models that combine pharmacological treatments with lifestyle modifications and environmental control measures. These approaches have been shown to improve adherence and long-term outcomes. The current study highlights the need for similar integrated strategies in Saudi Arabia, particularly for urban populations with higher exposure to environmental triggers.^[29]

Impact on quality of life

The average quality-of-life impact rating of 6/10 in this study aligns with findings from Middle Eastern and global research, which consistently highlight moderate to severe impairments among individuals with eczema and asthma. These conditions impose significant physical, emotional, and social burdens. A 2020 meta-analysis of studies from the Middle East reported that individuals with atopic diseases often face stigma, reduced productivity, and mental health challenges, such as anxiety and depression.^[30] The findings also reflect the ongoing challenges in achieving optimal symptom control. Despite active treatment, many participants in the current study continued to experience disruptions in their daily lives, underscoring the need for comprehensive care that addresses not only physical symptoms but also psychological well-being.

Strengths

This study on AE and asthma in the Saudi population offers several key strengths. Firstly, the sample size of n = 579 participants is substantial, which enhances the robustness of the findings and allows for a comprehensive analysis of the prevalence and severity of these conditions across various demographic groups. The study’s inclusive approach, which captures data across age, gender, and geographic regions, allows for a diverse representation of the Saudi population. This diversity enables a thorough examination of potential factors influencing the prevalence and management of atopic diseases, including genetic predisposition, environmental exposures, and lifestyle behaviors. Another strength lies in the study’s statistical rigor, particularly in the use of logistic regression to identify key predictors of disease prevalence and severity. The study provides important insights into how genetic factors, such as family history, and environmental triggers, like allergen exposure, contribute to the manifestation of these conditions.

Additionally, the high reliability of the data collection tool, as indicated by a Cronbach’s alpha of 0.87, further strengthens the validity of the findings, suggesting that the results are dependable and can serve as a foundation for future research and public health interventions. Moreover, the study highlights the significant impact of AE and asthma on participants’ quality of life, providing a valuable understanding of the emotional, social, and physical burdens associated with these diseases. The comprehensive data on symptom severity and treatment approaches also offer insights into the gaps in current management strategies, which could inform improvements in healthcare delivery and intervention programs.

Limitations

This study offers valuable insights into the prevalence and impact of AE and asthma within the Saudi population, but it has notable limitations. The cross-sectional design limits the ability to establish causality or assess long-term disease progression. Urban bias in the sample, with most of the participants from urban areas, may affect the generalizability of findings to rural populations. Data collection relied on self-reported questionnaires, introducing potential recall and social desirability biases. Despite these constraints, the study highlights key areas for future research, including the need for longitudinal designs and more comprehensive assessments of environmental and psychological factors. The study’s reliance on self-reported questionnaires introduces recall bias, where participants may underestimate exposure to environmental triggers or overstate treatment adherence, while the cross-sectional design and urban bias limit the ability to establish causality and generalize findings to rural populations. The data is susceptible to biases that can inflate reported rates: Self-Reported Diagnosis (Recall Bias): The study relied on a questionnaire. Participants’ self-reporting of a “physician-diagnosed” condition is less stringent than a clinical examination or review of medical records. Patients may over-report past diagnoses, especially for chronic, well-known conditions like asthma or eczema. Symptom-Based Capture: The questionnaire likely included questions about symptoms. This approach captured a broader group of people who have experienced symptoms but may not have a current, severe, or formally confirmed diagnosis, thereby boosting the prevalence figure compared to studies that only count current, physician-diagnosed cases.