Approaches to Managing Patients With Atopic Dermatitis
In this video, dermatologist Steven Feldman, MD, PhD, speaks with allergist and immunologist Jason Caldwell, DO, and pediatric dermatologist Robert Sidbury, MD, MPH, about the multidisciplinary approach in the management of patients with atopic dermatitis (AD), including current guidelines, the impact of AD on a patient's quality of life, the role of allergy testing and asthma screening, and when to refer a patient to a specialist.
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Steven Feldman, MD, PhD, is a professor of dermatology at Wake Forest University School of Medicine and a dermatologist at Atrium Health Wake Forest Baptist Medical Center (Winston-Salem, NC).
Jason Caldwell, DO, is an associate professor of pulmonology, critical care, allergy, and immunologic diseases at Wake Forest University School of Medicine and a pediatric allergist at Atrium Health Wake Forest Baptist Medical Center (Winston-Salem, NC).
Robert Sidbury, MD, MPH, is the division chief of dermatology and an associate professor in the Department of Pediatrics at Seattle Children’s Hospital (Seattle, WA).
TRANSCRIPTION:
Dr Steven Feldman:
Today we're going to discuss assessing atopic dermatitis. First, let's introduce our participants. I'm Steve. I'm on the faculty at Wake Forest University School of Medicine, where I'm a professor of dermatology, and I'm joined by my friend Dr Jason Caldwell, a pediatric allergy and immunology specialist at Atrium Health, Wake Forest Baptist Medical Center and associate professor of pulmonology critical care, allergy and immunologic disease here at Wake Forest, we also have Dr Robert Sidbury, Division Chief of Dermatology, an associate professor in the department of pediatrics at Seattle Children's in Seattle, Washington. Gentlemen, to start, atopic dermatitis has so many manifestations and maybe multiple specialties should be involved. Tell me about what your role is and the importance of a multidisciplinary approach to the management of patients with atopic dermatitis. Jason, let me let you start.
Dr Jason Caldwell:
Well, our role can be multifaceted. We can sometimes see atopic dermatitis. We can maybe answer some questions about allergies or triggers for atopic dermatitis, and of course, go from standard care treatments up to biologics such as Dupixent.
Dr Steven Feldman:
Those triggers are so critical, so I always wonder, in my patients even more than I do, to what extent allergy is causing atopic dermatitis and its flares. Now in our dermatology clinic, we do patch testings for allergy, but that's the only kind of allergy testing we do. In the allergy world, what do you find helpful for atopic dermatitis?
Dr Jason Caldwell:
Well, actually that's a great question because many times allergy testing for IgE in people with atopic dermatitis, is actually not very helpful. We know that a third of people with atopic dermatitis, at least a third of children, will have a positive, but that doesn't mean it's clinically significant. So you have to counsel the parents more to understand what foods may be causing it by recognizing the trigger and causing the flare and then avoiding those foods.
Dr Steven Feldman:
Do foods cause all types of... If I have somebody who's got that typical atopic dermatitis in front of their elbows behind their knees, is that something that might be coming from food allergy?
Dr Jason Caldwell:
I like to think, and hopefully, I'm thinking correctly, but atopic dermatitis is multi-genetic disease that comes together to form it. And I like the things that foods don't actually necessarily cause it, but they make it worse or they can make it flare because even if you do complete elimination diets, you can still have some atopic dermatitis breakthrough, even if there is a food that has caused a flare and you're avoiding it.
Dr Steven Feldman:
All right. Bob Sidbury, you see the kids. Are you seeing much in the way of allergy in this population?
Dr Robert Sidbury:
Oh, I do. Yeah, I agree with everything that you and Dr Caldwell have said. First and foremost, atopic dermatitis is a multifactorial disease. As you said, it's a family disease, sleep loss, all the things we'll talk about later affect the whole family. So for sure, it's multidisciplinary. And from an allergy standpoint, the only thing I'll really add to what was said was a lot of times parents are so desperate to find a trigger to remove, and for the reasons just described, it's oftentimes not just one thing, it's multifactorial that they'll push testing when we may not feel, based upon the history, that testing is indicated. And oftentimes their answer is, "Oh, well, it's just good information." And for the reason Dr. Caldwell said it's sometimes confusing information and you can get false positives, that then the parents will remove a food that's being tolerated perfectly well because of that test result, and that's actually a way to cause food allergy. So I'm always really careful to try and go through with parents the double-edged sword of allergy testing in this context.
Dr Steven Feldman:
Robert, I know you've been involved with guidelines. Do the guidelines say anything about allergy testing or other things about taking a multidisciplinary approach?
Dr Robert Sidbury:
They do. Back in 2014, that iteration said not much more than that. Just that indeed, all of these things we've said, it's a multidisciplinary problem and some very well-known comorbidities, asthma, food allergies, hay fever, and to consult appropriate specialists when those are more of the focus. A more current iteration has expanded the list of comorbidities to a remarkable degree and so all of these points are just reemphasized in the newer version that's just been published this year.
Dr Steven Feldman:
I take care of a lot of patients with psoriasis and have learned to screen for arthritis comorbidity. I know asthma's more common in kids with atopic, but I've never been one to ask about asthma or try to evaluate it or manage it. What more should I be doing?
Dr Robert Sidbury:
Certainly, as a pediatric dermatologist, I imagine Dr. Caldwell is managing perhaps more of this directly than I am. I just ask the questions in terms of how they're breathing, do they get sick and then begin to wheeze? And if there is, I'll certainly listen to their lungs, and if there are any indication that they have asthma, I'll refer them back to their pediatrician. But that may be more deferential approach than Dr. Caldwell takes. I don't know.
Dr Jason Caldwell:
A better name for allergy immunology would actually be allergy, asthma, and immunology. So we look at the atopic march as a whole and not just one part, so the atopic march through asthma, seasonal allergies, and even food allergy and atopic dermatitis. And we can use that in different ages to know when to screen for people. And allergists like myself, certainly treat asthma as a main part of our discipline.
Dr Steven Feldman:
Do you have any recommendations for what kind of screening, if any, I need to do when I see an atopic patient and think about referring them to you?
Dr Jason Caldwell:
Some of the simple questions, in children especially, is asking about cough. Cough is probably the number one sign of asthma. And then if you're coughing at night and waking with a cough more than two times a month, and if you have albuterol and you are using it more than two times a week, then that's something that would be necessary to call persistent asthma and needs to be managed either by a pediatrician or pulmonologist or an allergist-immunologist.
Dr Steven Feldman:
I imagine that asthma and its effect on sleep, as well as a topic effect on sleep, has dramatic effects on people's lives. Jason, is that what you're seeing?
Dr Jason Caldwell:
Oh yeah, definitely. It correlates with atopic dermatitis, and as our colleague mentioned, it affects the whole family. You're having exacerbations, everybody's up at night, you're missing school, and performance in the child may be lessened if they're getting all this sleep and if they have both going on and they're not controlled, it's just magnified.
Dr Steven Feldman:
Robert, is anything else I should be thinking about in that regard with kids?
Dr Robert Sidbury:
Yeah, the only other thing I would say is, again, touching back, the fact that these expanded lists of comorbidities come out is the pretty strong evidence now that kids with atopic dermatitis, at least moderate to severe disease, are more likely to have ADHD, attention deficit hyperactivity disorder. Now, there's an easy way to have a child, just as Dr Caldwell is saying, they're exhausted, they're losing sleep because of their itch at night, the teachers are saying, "Oh, they're fidgety. They're not paying attention." Well, they have bad eczema. They're not sleeping well. Maybe. They may also have a separate disease that would present similarly but be treated differently. So just be aware of that link.