Diagnosis of Atopic Dermatitis

Lawrence F. Eichenfield, MD: A secondary theme is the subset of patients whose diseases are not well controlled. Let us take an overview and then talk about the management of atopic dermatitis and how it is across a spectrum. There are patients doing it on their own, pediatricians, other primary care practitioners, and then specialists: usually dermatologists or pediatric dermatologists, allergists, and occasionally other groups depending on how people seek their care. 

Let us start by discussing who are typically diagnosing and treating patients with atopic dermatitis. Then we will discuss the awareness in the physician community. Who is doing the core work? Jeff, why don’t you lead off? Pediatricians are often the ones who start off. 

Jeffrey M. Bienstock, MD, FAAP: That is the answer. We are the ones who often start off because, as primary care doctors, we are seeing the children first for the most part. However, as I have said before, sometimes it is a parent who may have had atopic dermatitis when they were younger. Sometimes a grandparent says, “I know this other family that has something similar.” But we are the ones on the front line making that initial diagnosis.

Because we have been doing this a little longer, hopefully many of us make the correct diagnosis. That is very important. Making that diagnosis right off the bat can help the family, as compared with setting them down a road where they are purchasing things that are not necessary and coming back 3 days, 5 days, or 2 weeks later saying, “Things are not better.” The treatment course did not match the illness. That’s very important.

It’s very important to make sure that the pediatrician is aware and to have forums like this. Some pediatricians think it is an easy diagnosis to make and that the treatment is simple, but that may not be the case. They need to look at everything around them. We talked about the triggers and other things that sometimes make the diagnosis not that easy to make. A good pediatrician—someone who is aware, who has been trained correctly, who listens, who attends or listens to a forum like this—will be able to make that diagnosis and then give the appropriate treatment and take that child off. Not that there are not going to be some children who just do not respond, or that some pediatricians might feel a little uncomfortable moving up the ladder on treatment. 

Lawrence F. Eichenfield, MD: Lisa, do you want to weigh in?

Elizabeth A. Swanson, MD: Pediatricians are usually the ones making the initial diagnosis of eczema or atopic dermatitis, but there is a large spectrum of comfort levels in managing the condition among pediatricians. Some of them were given a lot of exposure to dermatology in their residency and training, so they feel very comfortable prescribing appropriate therapy. They will wait to send the patient to somebody like me because they feel comfortable doing a first- or second-line routine.

Then there are other pediatricians who think, “Oh, skin stuff—I’m not good at that,” and then I get the referral earlier. They are very good at making the diagnosis, but there is a spectrum of comfort levels with managing the diagnosis in the pediatrics world. 

Lawrence F. Eichenfield, MD: Let us switch from our perspective for the specialist here. At what point do you believe patients are seeking care?

Elizabeth A. Swanson, MD: They seek care right away. The condition is so itchy and so disruptive to sleep and life and everything that they seek care right away—at least to the pediatrician. If they get referred, they get referred. If they seek to see a specialist without a referral, they do that too. Families are desperate to make this better. It is hard even in the office to watch a little baby with horrible eczema scratching, itching, uncomfortable, and crying. That is for 10 or 15 minutes in the office. Imagine having that around you all the time. Parents are very eager to seek treatment for their kids with atopic dermatitis.

Lawrence F. Eichenfield, MD: I find that there is some variability. The literature shows this mixed thing where there are high levels of referral, but there is lots of care being given by the primary care community. I will skip to my takeaway. Of all the diseases I deal with, atopic dermatitis is unique in having the most moderate-to-severe patients who are in terrible shape but have either accommodated to the disease or believe that is the way they must be because there are not good treatments. Some may be untrusting or uncomfortable with treatments that have been proposed, and so they live their life that way. This is something that we are in the process of changing, but it is a revolution to get to the patients to understand that they do not need to be that way and that we have different approaches. 

The best analogy I use for the families is that if your child has asthma, your child is wheezing all the time. You figure if they wheeze badly, you might bring them to the emergency department to get treated. We do not do that. Our more successful approach is getting your child to not wheeze and then whatever control or medicines we need to keep them wheeze-free as much as possible. It is a different psychology. 

Peter, are you seeing more issues with misdiagnoses leading to long periods of treatment or just not enough treatment?

Peter A. Lio, MD: By far, my experience has been undertreatment. The fortunate aspect is the diagnosis tends to be straightforward, although I must admit that more recently, I am getting some very bizarre cases referred in and I do have a number of chronic refractory cases that I am seeing. Sometimes we have to start from scratch. I’ve had a couple of cutaneous T-cell lymphoma cases that have been masquerading as severe, nonresponsive atopic dermatitis.

We have a lot of contact dermatitis where that is the real diagnosis, but much more commonly it is just a confounding diagnosis. Once we remove those contactants, they get a little better. They start responding, but they did have true underlying atopic dermatitis. Sometimes, although rarely, we will see completely off things, like scabies masquerading as atopic dermatitis well. I often think we must go back if they are not responding because sometimes, we are treating the wrong thing.

Transcripts Edited for Clarity