Challenges in Diagnosing Pediatric Atopic Dermatitis (AD)


Brittany Craiglow, MD, and Angela J Lamb, MD, discuss the varying presentation of atopic dermatitis (AD) among different skin types and skin color, as well as the challenges in gauging disease severity.

Brittany Craiglow, MD: Hi, thank you for joining this Contemporary Pediatrics video series. I’m Dr Brittany Craiglow, MD, a double board-certified dermatologist and pediatric dermatologist. I practice in Fairfield, Connecticut, and I’m affiliated with Yale University. I am joined today by Dr Angela J. Lamb, MD.

Angela J. Lamb, MD: Hi, how are you? Thank you. I am located in New York City. I’m an associate professor of dermatology at the Icahn School of Medicine at Mount Sinai. I’m also medical director of our faculty practice access center and vice chair of clinical operations and strategy for the Department of Dermatology.

Brittany Craiglow, MD: It sounds like you’re very busy. In today’s discussion, we will highlight a patient case and discuss the importance of collaborative and multidisciplinary care in pediatric patients who are suffering from atopic dermatitis. Let’s start first by discussing some of the challenges in diagnosing pediatric atopic dermatitis. Is it usually straightforward, or are there cases that might be a little harder to tell if it’s AD [atopic dermatitis] or something else?

Angela J. Lamb, MD: For us as dermatologists, it’s straightforward. What can get cloudy is when patients and their families come in and have other ideas about what it is. They think they definitely have an allergy. They think it’s definitely something in the environment, perhaps something they’re eating, which we know can contribute to atopic dermatitis. But unfortunately, atopic dermatitis, as you know, is an intrinsic issue with the skin and the immune system. So, the diagnosis is clear, but then you have to bring people back around to convince them that what you think it is [is] consistent with what they think it is.

Brittany Craiglow, MD: I do think, importantly, it can look different in different patients. Classically, the descriptors are red, dry, and scaly, but not everybody fits that. And among different skin types, it can look different. Tell us a bit about different presentations and how they vary.

Angela J. Lamb, MD: What I find, [and] what’s been documented in the literature, is that [in] folks who have more melanin in their skin, atopic dermatitis tends to be more papular. Instead of having that classic bright-red erythema, [it usually has] more of a maroon color. That’s masked sometimes by some unification. With papular distribution, it tends to be more on the abdomen. Especially in younger children, I’ll see that they’ll lift up their shirt and they’ll say they have all of these little dots. And I’ll say, that’s the more papular form of atopic dermatitis seen in people who have more melanated skin.

Brittany Craiglow, MD: It can be subtle, sometimes. I tell the [medical] residents that you don’t make a diagnosis from the door, you have to get close. Sometimes, there’s this impression that if it isn’t fire-engine red, it’s not bad, but especially papular AD can be extraordinarily itchy and also a lot harder to treat with topicals. Remembering the patient experience and what you see doesn’t necessarily correlate with how they’re feeling, and asking about itch and the impact on their life [is] important.

Angela J. Lamb, MD: Yes.

Brittany Craiglow, MD: Moving toward that, what are some of the things that you think about when you’re trying to assess severity in a patient with atopic dermatitis?

Angela J. Lamb, MD: The classic sign we look for is erythema. We look for edification, we look for surface area involvement, but also I like to ask people what’s going on in their life. Especially for kids, you want to look at it as, is this disrupting your ability to go to school? Is it disrupting your ability to concentrate in class? For families, is it disrupting the child’s sleep? Those are some of the critical things to ask. There are assessments that take that into account, but as physicians, sometimes when we’re in the room, we’re not necessarily asking about that, and we don’t always have that checklist in front of us. But it’s important to understand how much it’s impacting someone’s life because you may have a low disease burden by surface area coverage, but that thick plaque on your hand or that one thick plaque on the popliteal fossa can have people scratching it up all night.

Brittany Craiglow, MD: One-hundred percent, I agree. These classic measures, the more objective measures of severity, are useful, but they don’t paint the whole picture. We need to find out how that person in front of us is doing and how they’re experiencing it. And that’s different. And asking about itch is important. I often say to my patients, on a scale of 1 to 10, how itchy are you? One is not a big deal, 10 is ruining your life. And importantly, we’re catching them at one moment in time. By nature, atopic dermatitis waxes and wanes, so maybe they’re having a good day today, but what have the past few months been like? Getting that history, too. I like your holistic approach. How does it look? How do they feel?

Transcript edited for clarity

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