Multidisciplinary Management in Pediatric Atopic Dermatitis

Melodie Young, NP: I want to discuss all the people who are involved in taking care of a child with AD [atopic dermatitis]. There’s a strong familial linkage, and often you won’t just have 1 child with atopic dermatitis, there tends to be a parent, cousin, or other family members who have some AD as well, and so, it can be very overwhelming. It takes a team, and in our clinic, it’s the front desk that knows when these people call that if we don’t get them in they’re going to go to urgent care; in urgent care they want to give them systemic steroids, which we all hate. There’s an issue sometimes with getting referrals because we’re specialists. Sometimes we must work around school and family work issues, these people seek a lot of health care services. There are many folks in our clinic involved, the medical assistants. Let’s talk about the role of NPs [nurse practitioners] and PAs [physician assistants]; a lot of what we do is similar to what our physician colleagues do with taking care of these patients. But we know that we as NPs and PAs are seeing a higher proportion of medical dermatology patients. Does anybody want to chime in on what you think NPs can do well with this population?

Lakshi Aldredge, MSN, ANP-BC, DCNP: I’m happy to discuss the role of nurse practitioners in atopic dermatitis management. It takes a village, and NPs are uniquely suited to care for this group of patients. We cover the entire gamut of the lifespan, starting from infancy to later adulthood, NPs can care for these patients, both in the primary care setting and as dermatology specialists. It is important to look at the whole patient as well as the family unit. Take into consideration, as Matthew mentioned, the psychosocial aspect of the disease burden, and then look at other underlying conditions that may contribute to atopic dermatitis. Do the patients have adequate nutrition? What is their housing situation like? What is their financial situation? What is the emotional balance of the family unit, and the individual? All of these play a huge role in the management of atopic dermatitis. This is not just a dry skin condition. And because it can have such an impact on the entire family and the development and success of the individual throughout their lifespan, NPs and PAs are uniquely qualified to take time, both at the physical examination visit, but also in follow-up visits, whether it’s phone visits, telehealth. It’s important for these patients to feel that you have developed a relationship with them, that you’re in it as the provider for the long haul of the disease journey with these patients. This isn’t a one and done, perhaps like a skin cancer visit or a skin infection visit. This is a disease where a therapeutic relationship is essential, and it’s important that you include all members of the family, and that you provide hope and longevity with these patients.

Melodie Young, NP: Matthew or Alexa, tell us about your role, and what you see as the role of PAs in taking care of this population.

Matthew Brunner, PA: Our role is being those patient educators, making sure that the entire family unit understands how to care for the patient and continuing to reinforce that. Patients remember about 20% of what we tell them, and so we must continue to reinforce that on follow-up visits. Even more importantly, it’s that we as providers, PAs and NPS alike, are beginning to help the discussion with our patients to understand that this is not just a disease that you see on the surface of the skin. This is a systemic disease, and there is an autoimmune component, that it’s highly driven by Th2 and Th22 [T helper cells]. There is systemic inflammation, and even when we don’t see a flare, the skin of a patient with atopic dermatitis is not the same as the skin of a patient who doesn’t have atopic dermatitis. It’s accepting, understanding, helping to communicate with our patients, and making them better users of the health care system and knowledgeable on what’s going on with their skin or the skin of their child as they begin to enter young adulthood.

Melodie Young, NP: Alexa, do you have anything else? Any other comments on this section?

Alexa Hetzel, MA, PA-C: The 2 things I think of are education and empathy. We are well educated to treat these patients, but we must be empathetic and understanding of what they’re going through. We can educate them until we’re blue in the face, but unless they understand that we understand, I think you’ll have a disconnect. I always like to share with my patients that I’m a new mother, I totally get that panic of, “Oh my God, what do I do?” And to have somebody in your corner makes the whole treatment process a lot smoother on both our end and the patient’s end.

Melodie Young, NP: Another important thing is availability. NPs and PAs by the thousands are now in the specialty, because we want to keep the dermatologic care within our clinics and not have them going from place to place. If we’re not available that’s a problem. One thing we do well is understanding all the other comorbidities associated with this. We talked about asthma and severe allergic rhinitis that you often see, some psychiatric problems and psychological impacts, higher diagnosis of hyperactivity, and insomnia, their growth patterns, as Lakshi mentioned, whether they are meeting their developmental milestones. It’s important to have an understanding of these pieces and helping, as Matthew mentioned, to explain that it’s not just a skin situation, this is a body-wide disease. These proinflammatory cytokines are manifesting in the skin, lungs, or the sinus or nasal passages that cause the AD to develop. We must think about that.

Also, developing that relationship or rapport, so the family knows that we will do our best to bring them the best therapeutics, education, and empathy. They need somebody to understand how expensive all of the products are that we suggest they buy, and how many visits it can take for some of the things we’ve done in the past. I always felt so bad when we used phototherapy, because it’s problematic for a family to get a child over for phototherapy multiple times a week, pay copayments, and then help with their bath time; it’s a big thing.

Transcript Edited for Clarity