Adverse Childhood Experiences and Pediatric Dermatology: Implications for Care, Equity, and Research

ABSTRACT

Adverse childhood experiences (ACEs) are increasingly recognized as important determinants of lifelong physical and mental health through mechanisms involving chronic stress, immune dysregulation, and inflammation. Although ACEs have been associated with numerous chronic medical conditions, their relevance to pediatric dermatology has received comparatively little attention. Existing evidence directly linking ACEs to dermatologic disease is limited and focuses primarily on atopic dermatitis and psoriasis, while research involving other pediatric skin disorders has largely examined psychosocial stress, trauma, or social drivers of health using heterogeneous frameworks. This fragmented approach limits the ability to compare findings across conditions and to understand how cumulative early‐life adversity influences disease onset, severity, treatment response, and quality of life. In this commentary, we review the current evidence connecting ACEs and dermatologic disease, distinguish ACEs from broader social drivers of health, and identify critical gaps in the pediatric dermatology literature. We discuss methodological considerations for incorporating ACE measures into pediatric dermatology research and outline practical, trauma‐informed approaches for integrating awareness of early‐life adversity into clinical care. Pediatric dermatologists care for children during the developmental period in which ACEs occur and often develop long‐term therapeutic relationships, positioning the specialty to advance understanding of how cumulative adversity shapes skin disease trajectories. Greater incorporation of ACE‐informed frameworks into research and clinical practice may improve understanding of pediatric skin disease and support more holistic, patient‐centered care.

1. Introduction and Background

Pediatric dermatology occupies a unique space at the intersection of longitudinal care, social context, and health trajectories. Many pediatric skin conditions arise early in life, involve chronic disease states, and follow variable courses through childhood and adolescence. Beyond physical symptoms, these conditions both influence and reflect children's daily routines, built environment, peer relationships, family dynamics, and overall patient and family well‐being. Pediatric dermatologists routinely care for children whose disease course is inseparable from the contexts in which they live, yet the tools used to conceptualize those influences remain fragmented and inconsistent.

Adverse childhood experiences (ACEs) offer one potential framework for addressing this gap. First described in a landmark 1998 study by Felitti et al., ACEs encompass experiences such as childhood abuse, neglect, and household dysfunction, and emphasize the cumulative effects of early adversity on long‐term health [1]. The ACE framework is commonly operationalized using 10‐item questionnaires derived from the original study [1] and subsequent ACE‐10 research [2] (Figure 1). Over the past two decades, higher ACE scores have been consistently associated with increased risk of chronic disease throughout life and premature death [3, 4]. These associations are thought to reflect durable biological and behavioral consequences of early adversity, including stress‐axis dysregulation, altered immune function, and chronic inflammation [5]—pathways highly relevant to dermatologic disease.

FIGURE 1.

The 10‐item Adverse Childhood Experiences (ACE‐10) questionnaire. ACE score equals the sum of affirmative responses (range: 0–10). Adapted from Kovács‐Tóth et al. [2] under the Creative Commons Attribution (CC BY) license. The ACE framework was first described by Felitti et al. [1].

Unlike approaches that focus on isolated stressors, ACEs emphasize cumulative exposure during sensitive developmental periods and have been proposed as a standardized method for capturing early life adversity in pediatric clinical and population health research [6]. This emphasis on cumulative experience closely aligns with principles of trauma‐informed care and social drivers of health, approaches increasingly adopted across medicine that recognize how life experiences shape health outcomes and how patients and families engage with medical care.

Despite this conceptual overlap, ACEs have received limited direct attention within pediatric dermatology. Instead, stress, trauma, and economic factors influencing disease course are more often examined in piecemeal ways that vary across conditions and studies, limiting the field's ability to engage with early life adversity in a systematic, comparable, and developmentally informed manner. Clarifying what is currently known, where evidence remains thin, and how ACE frameworks might be thoughtfully applied therefore represents an important next step in advancing understanding within pediatric dermatology.

2. Adverse Childhood Experiences in Dermatology: Current Evidence

At present, direct evidence linking formally measured ACEs to dermatologic disease is limited and narrowly focused. Studies have examined atopic dermatitis and psoriasis, making these conditions key early anchors for direct ACE‐based inquiry in the field. In a longitudinal birth cohort study, children exposed to more ACEs had higher odds of atopic dermatitis in early childhood [7], suggesting that adversity may be associated with disease risk during critical developmental periods, particularly at ages when children are unable to fully participate in their own care routines. ACE‐specific studies in psoriasis have been conducted largely in adult populations, where higher ACE exposure was reported among affected patients compared with controls, raising the possibility that early adversity may play a role in immune‐mediated inflammatory skin disease across the lifespan [8].

Outside of atopic dermatitis and psoriasis, dermatology has engaged with early life adversity mainly through broad psychosocial and social drivers of health literature rather than ACE‐specific frameworks. In clinic‐based and case–control studies, higher rates of childhood and lifetime trauma have been reported among patients with chronic urticaria, alopecia areata, and hidradenitis suppurativa, with trauma exposure linked to disease burden and psychosocial comorbidity [9, 10, 11]. Studies in conditions such as vitiligo and hidradenitis suppurativa have demonstrated associations between perceived stress or psychosocial burden and disease characteristics [12, 13]. In parallel, lower socioeconomic status has been associated with both higher risk of ACE exposure [14] and worse dermatologic disease outcomes more broadly [15].

3. Gaps in the Literature

What is known is that early adversity is relevant to pediatric dermatology, but what is missing is scope and cohesion. Direct ACE‐based investigations are confined to atopic dermatitis and psoriasis, immune‐mediated conditions linked to stress‐responsive inflammatory pathways that make them logical starting points for ACE‐focused inquiry. However, it remains unknown whether similar patterns would be observed across other immune‐mediated skin diseases, such as alopecia areata or hidradenitis suppurativa. It is also unknown whether cumulative adversity plays a comparable role in non‐immune‐mediated conditions and, if so, by what mechanisms this could occur.

Outside of atopic dermatitis and psoriasis, adversity and structural disadvantage in dermatology have so far been examined through heterogeneous measures of stress, trauma, or deprivation, making it difficult to integrate findings across diseases and contexts. As a result, it remains unclear how cumulative ACE exposure and socioeconomic status, which represent distinct but often overlapping dimensions of early life context, relate independently or jointly to key clinical outcomes such as disease onset, severity trajectories, or psychosocial burden. Without broader and more cohesive investigation, the role of adversity in shaping pediatric dermatologic outcomes remains incompletely defined.

4. Why Early Life Adversity Matters for Pediatric Dermatology

The absence of ACE‐focused evidence in pediatric dermatology limits understanding of how cumulative adversity may influence disease development, severity trajectories, flare patterns, and treatment response. Apparent treatment failure or fluctuating symptom control may reflect not only biologic variability but also contextual factors shaped by early or ongoing adversity. In the absence of data, these distinctions remain speculative, limiting the ability to anticipate risk or further individualize care.

Beyond disease metrics, ACEs capture dimensions of a child's lived experience that are rarely visible during a dermatologic encounter. Although ACEs and social drivers of health frequently overlap, they represent distinct dimensions of patient context. ACEs emphasize cumulative interpersonal and developmental adversity occurring during childhood, whereas social drivers of health describe broader structural and environmental conditions that shape health outcomes, access to care, and treatment adherence. These factors may influence dermatologic outcomes through overlapping but partially distinct biological, behavioral, and structural pathways, although the relative contribution of these mechanisms remains poorly understood. For example, a child with new‐onset alopecia areata may be navigating cumulative interpersonal stressors captured through ACE frameworks, while simultaneously experiencing structural barriers to treatment or follow‐up reflected by broader social drivers of health. Distinguishing between these domains may therefore help clarify whether disease burden is more closely related to cumulative developmental adversity, structural barriers to care, or both, with different implications for clinical support and intervention.

ACE‐informed thinking also aligns with broader principles of trauma‐informed care already adopted across medical specialties: approaching patients with an awareness that unseen experiences may shape behavior, adherence, and outcomes. In pediatric dermatology, where care is longitudinal and relationships often develop over years, consideration of early‐life adversity may help clinicians interpret chronic disease within a broader patient context.

5. Moving the Field Forward

Pediatric dermatology must begin to incorporate ACE frameworks into research and clinical thinking. To date, ACE‐specific investigations have focused almost exclusively on atopic dermatitis and psoriasis, leaving most pediatric skin diseases unexamined through a cumulative adversity framework. In contrast, other pediatric and adult disciplines caring for patients with chronic conditions have begun to systematically examine how ACE exposure may relate to disease trajectories and long‐term outcomes. Given that pediatric dermatologists care for children during the developmental periods in which ACE exposure occurs and follow many longitudinally, our field is well positioned to deepen understanding of ACEs. Advancing this work will require thoughtful approaches to measuring, interpreting, and applying ACE‐related information within pediatric dermatology research and care.

Studying ACE exposure in pediatric populations presents several methodological considerations. Early ACE research relied largely on retrospective data from adults about experiences occurring before age 18, while more recent studies have included adolescent populations and pediatric screening tools that rely on caregiver‐reported adversity for younger children. Large population datasets such as the National Survey of Children's Health, which includes caregiver‐reported ACE measures and dermatologic outcomes such as eczema, and the Behavioral Risk Factor Surveillance System, which incorporates ACE modules used in epidemiologic research, provide opportunities to examine relationships between adversity exposure and population health outcomes. In addition, some integrated healthcare systems, including Kaiser Permanente, have incorporated ACE screening into routine clinical care and documented these data within electronic medical records, allowing adversity exposure to be examined alongside clinical outcomes. Longitudinal pediatric studies may also help clarify how ongoing, past, and cumulative adversity differentially influence disease trajectories over time. Investigator‐initiated studies within academic medical centers may extend this work by incorporating ACE measures directly into dermatology research cohorts. However, studying adversity in pediatric populations also raises important ethical and practical considerations. Asking children or caregivers to report experiences of trauma may surface adversity that is ongoing, requiring thoughtful approaches to screening, clear pathways for support, and careful attention to how sensitive information is documented and protected. Importantly, ACE‐informed screening or discussion should ideally occur within systems that have access to appropriate support services, such as social work, mental health professionals, primary care partners, or community resources, so that identified needs can be appropriately addressed.

Practical integration of ACE‐informed approaches into pediatric dermatology will likely require collaboration rather than universal dermatologist‐led screening. In some healthcare systems, screening for ACEs or social needs is already incorporated into pediatric primary care or electronic medical records, allowing dermatologists to incorporate existing psychosocial context into clinical decision‐making. In select situations, such as new‐onset, treatment‐refractory, or stress‐associated disease, dermatologists may incorporate open‐ended discussion of psychosocial stressors or review existing ACE or social needs screening documented elsewhere in the medical record. For example, if the child with newly diagnosed alopecia areata later develops recurrent flares, a dermatologist may ask, “Some patients have reported that stress plays a role in their condition—are there any recent circumstances in your life that have been especially stressful to you?” These trauma‐informed discussions of patient circumstances and psychosocial stressors may represent feasible initial strategies in select clinical contexts, while evidence guiding when and how ACE‐informed assessment should be incorporated into pediatric dermatology care continues to evolve.

ACE frameworks may help pediatric dermatologists better contextualize disease trajectories and patient experiences within broader developmental and social settings. 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.

Author Contributions

M.H. conceptualized the manuscript and wrote the initial draft. S.J.C. provided supervision and critical revisions of the manuscript. Both authors approved the final manuscript.

Funding

This project was funded through the 2025 Pediatric Dermatology Research Alliance (PeDRA) Fellowship Award.

Conflicts of Interest

Dr. Sarah J. Coates is a section editor of the Arts and Humanities section for the Pediatric Dermatology journal.

Data Availability Statement

Data sharing not applicable to this article as no datasets were generated or analyzed during the current study.