Diagnostic Challenges Facing Patients with Atopic Dermatitis


Key opinion leaders navigate diagnostic challenges associated with atopic dermatitis.

Casey Butrus, PharmD: Dr Cameron, what are some diagnostic challenges you experience with your patients with atopic dermatitis [AD]?

Michael Cameron, MD, FAAD: For classic AD—thickened, pink, scaly plaques on the flexural surfaces of the arms or legs—it’s not a diagnostic dilemma. So I’m not doing a skin biopsy or anything like that; it’s a pretty easy diagnosis. The challenge is in treating it, and we’re going to discuss that. But AD can present in different ways. Sometimes you have atypical manifestations of atopic dermatitis when you’re not quite sure if it’s AD. If they have palmoplantar predominance, you’re thinking, “Is this palmoplantar psoriasis, or is this a hand-foot dermatitis presentation manifesting as a version of AD?” That’s when it can get difficult.

It can also get difficult if it’s widespread and you’re worried about cutaneous lymphoma. That’s always in the back of my mind. We never want to miss a cutaneous lymphoma because that’s a very different treatment approach; it’s a malignancy of the skin. Those are the things I’m thinking about. But for classic bread-and-butter atopic dermatitis, I don’t think of it as much of a diagnostic challenge as I do as a therapeutic challenge.

Casey Butrus, PharmD: You mentioned psoriasis. What are some other differential diagnoses that you try to exclude when you see a patient presenting with a rash or an itch?

Michael Cameron, MD, FAAD: A pink, scaly, itchy rash may be classic to a dermatologist, but others may not know for sure this is eczema. What are we thinking about on the differential diagnosis? That’s a great question. I always break it up into 3 baskets: inflammatory, infectious, and neoplastic. The inflammatory portion is psoriasis, atopic dermatitis, and then some lichenoid conditions like lichen planus and things like that. For my infectious differential, I’m thinking about predominantly fungus. Sometimes a fungal skin infection can look a lot like eczema. It can get even more confusing if someone has been treating their fungal infection with topical steroids, and it can become more popular and raised as the fungus goes deeper into the skin. Lastly, from the neoplastic perspective, I’m thinking a lot about cutaneous lymphomas and things of that nature.

Casey Butrus, PharmD: Thanks for providing that perspective. Some of the challenges we see with atopic dermatitis are just trying to differentiate it from other types of dermatitis we see with inflammation of the skin. Dr Keegan, how do you measure disease severity? Specifically in atopic dermatitis, but maybe for some other dermatologic conditions as well.

Brian Keegan, MD, PhD: That’s an interesting question. There are a lot of ways you can measure severity. Sometimes we use metrics. In a clinical trial, we might assess how severe their atopic dermatitis is: none, mild, moderate, or severe. There are varying criteria for that. We might also measure how much body surface area [BSA] is involved. But there are also things that can affect their quality of life as well. Are patients sleeping at night? Is it interfering with their ability to concentrate in school, at work, and in interpersonal relationships? Those have varying criteria. There are a number of questionnaire-type surveys to help to get a numerical assessment. But when I’m in the office seeing regular patients, I try to dig in to some of the psychosocial components of their life and understand how those are affecting them on a day-to-day basis.

Casey Butrus, PharmD: You bring up a good point about clinical trial measures. The Investigator Global Assessment [IGA] is used commonly in clinical trials, as well as the EASI [Eczema Area Severity Index] score. How often do you use those measures in clinical practice?

Brian Keegan, MD, PhD: I’ve used the Eczema Area and Severity Index in clinical trials. It’s a calculation that takes more time, and I don’t know if it brings a lot more to actual patient care. It’s important for clinical trials for numerical assessments. On the day-to-day, I try to assess every patient who comes in the office with how severe they are in terms of their IGA score and rating them. I try to get a relatively close assessment of how much body surface area is involved. Then ask a series of questions about how it affects their life at night, schoolwork, interpersonal relationships, sports activities, or whatever, depending on the age of the patient I’m talking to.

Casey Butrus, PharmD: From a managed care perspective, different health plans use different scores, maybe in their prior authorization criteria, to assess the disease severity of atopic dermatitis.

My next question is for Amy. When you’re going through a request for prior authorization, do you notice different health plans and payers require different diagnostic criteria, like the IGA or the EASI-75 score vs even an attestation of the disease severity?

Amy Brennan: Definitely. It varies from payer to payer. In our practice, we try to keep a protocol in place where we’re trying to use at least 1 or 2 of these scales for every visit. Things like BSA or an IGA scale are the easier ones for us to gather and make sure we have the time to get that for every patient. That way, if an insurance company is looking for clear documentation to prove the severity of their disease state, we have a numerical scale to give to them.

Casey Butrus, PharmD: Thank you. It’s important to emphasize what’s going on in clinical practice vs clinical trials and keep the providers in mind when we’re drafting prior authorization criteria.

Transcript edited for clarity.

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