Optimizing Multidisciplinary Care for Atopic Dermatitis


Lawrence F. Eichenfield, MD; Jeffrey M. Bienstock, MD, FAAP; Peter A. Lio, MD; and Elizabeth A. Swanson, MD, discuss the importance of an integrative approach to care for the management of atopic dermatitis.

Lawrence F. Eichenfield, MD: Peter, in your practice, how do you identify patients who are appropriate for allergy or multidisciplinary care outside what you’re bringing to it?

Peter A. Lio, MD: Many patients do require other disciplines to be involved. I don’t have the luxury of having everybody in 1 place at the same time, although that would be amazing. I have selected various providers around the city and even around the country. Some of my patients do telehealth, so I have connections everywhere. We really try to find the patients who have significant issues. I would say the vast majority—maybe 90%—of my severe patients also have an allergist. That’s almost a given.

Some of those patients will also have a nutritionist or a registered dietitian working with them, especially if they have a lot of food issues surrounding that. Sometimes I do an integrative approach and involve a psychologist or a hypnotherapist. I also work a lot with an acupuncturist and a sleep specialist. I can bring some of these other disciplines in, which is really neat.

My big thing is I really want to get to know those providers fairly well. I’m lucky. It took some time and was not easy. Sometimes colleagues will say, “What’s the secret?” There is no secret. It’s going out to lunch, having coffee, emailing, and getting to know them. To me, 1 of the most stressful things, as a provider but also I imagine for a patient, is when the 2 specialists are butting heads—when I’m saying 1 thing and the allergist is saying something else. I want that therapeutic alliance. If they hear the same message and they also hear, “Your allergist is fantastic. I love working with that allergist. I love working with that dietitian,” that really supports the patient as well, as opposed to conflicting advice. 

Lawrence F. Eichenfield, MD: I’m going to roll the question back and ask Jeff before it makes it to someone who’s an über-specialist, like Peter. From a primary care perspective, how do you decide who’s going out? How do you decide if it’s allergy or dermatology? How do you make that decision? What factors are you using?

Jeffrey M. Bienstock, MD, FAAP: It’s dependent on the patient—first, how severe they’re affected and the family dynamics. One of the things I love about primary care is making these relationships. As Peter said, it’s a cup of coffee, meeting them in the hallway, sending an email, sending a photo. That takes time.

I have lots of physician friends. I have lots of other friends as well, and people say, “You were able to make a phone call and get us an answer right away.” This happened last night, for example. I had a child with a cardiac issue. The mother said, “I had a stress test today with my daughter.” I asked, “Did you get the results?” She said, “No, they said they would call me tomorrow.” I got on the phone. I called the cardiologist right in front of her. She said, “How did you do that?” 

I said, “Well, I work with a select group of people.” The reason I’m able to do that as a team is so I can say when I can’t handle something and I want to send them to someone else or I want another person to take a look. Building relationships is something that takes a long time. Knowing my expectations and the expectations that I can fulfill for the parents is extremely important. 

Lawrence F. Eichenfield, MD: That’s great. Lisa, is your sense that there is a more active collaboration between allergy and dermatology? We’re hitting that age again where it’s easier.

Elizabeth A. Swanson, MD: Yes, I definitely do. About 5 or 6 years ago, I was still in Colorado, and I started working very closely with the allergists at National Jewish Health in Denver, Colorado. When I started doing that, I was nervous. Would our thoughts align with regard to things like atopic dermatitis, as Peter was saying? They totally meshed, and that collaboration ended up being 1 of the best of my professional career. I still work with them closely. 

I’ve gotten to know the allergists in the Boise, Idaho area really well, and I feel as though there is this new synchrony between dermatologists and allergists when it comes to atopic dermatitis. Maybe some of the new therapies have something to do with that. It has unified us in this goal to manage atopic dermatitis better. 

Lawrence F. Eichenfield, MD: I totally agree. Your conclusion for that is wise. It’s really important that both ends of this message should go out to health care practitioners, which is that it’s highly important to find people who become your team for when you need to get beyond what you’re able to handle in the office.

Also, don’t think the teams are going to be competitive as much as they used to be. Eczema is on a much more solid footing in terms of the evidence basis for management and treatment or understanding the disease and the disease impact. It’s easier to collaborate now than in the past. Even getting collaborators beyond who we spoke about—we even do a little overlap with our eosinophilic esophagitis people. It’s beyond just allergy and dermatology in primary care.

Transcript Edited for Clarity

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