Transcription:
Common Cases in Dermatology: Atopic Dermatitis

Andrew Wilner: Thanks for joining me for another episode of Pediatrics in Practice with Children's Mercy Kansas City. I'm your host, Dr. Andrew Wilner, Associate Professor of Neurology at the University of Tennessee Health Science Center and Division Director of Neurology at Regional One Health in Memphis, Tennessee.

My guests today are Dr. Brandon Newell and Nurse practitioner Rebecca Flynn. Dr. Newell is a pediatric dermatologist at Children's Mercy Kansas City, and an Associate Professor of Pediatrics at the University of Missouri, Kansas City. Nurse Practitioner Rebecca Flynn is a certified pediatric nurse practitioner working in dermatology who has worked at Children's Mercy Dermatology for nearly a decade. Together, we will discuss dermatologic conditions in children. Welcome, Dr. Newell and Nurse Practitioner Flynn.

Brandon Newell: Thanks for having us.

Rebecca Flynn: Thank you for having us.

Andrew Wilner: Yeah. Well, thanks for joining me. To get started, what's the most common pediatric dermatologic condition?

Brandon Newell: Probably one of the most common things that we encounter in clinic would be eczema or atopic dermatitis.

Andrew Wilner: And, you know, I'm just trying to get a kind of impression what you guys do all day. How do kids get that?

Brandon Newell: Well, it's multifactorial. It can run in families. We think a lot of it's environmental. Probably the initial eruption will occur early in infancy. Kids will develop it on their face or arms or legs and trunk. A lot of it's caused by an abnormal barrier function of the skin. And so their skin tends to lose lots of hydration. So their skin is very dry and cracked and very itchy. And then, everything from the outside that has dyes and perfumes and the irritants can get through the skin and trigger an inflammatory condition. So, kids will develop it in first few months of age, or sometimes they'll develop it around age one or two or most kids will develop it under age five. And so we'll kind of see the gamut of that age range.

Andrew Wilner: Wow. So it something that parents should bother taking their children to the dermatologist for? I mean, do you have any treatments for that that really help?

Brandon Newell: Most of the time for mild to moderate atopic dermatitis, most general practitioners or general nurse practitioners can handle this in their clinic. The mainstay of therapy is kind of geared at that daily maintenance routine of taking a bath every day with lukewarm water five or ten minutes, allowing that skin to kind of reabsorb that water. And then, we secondarily will soak and slather with a good moisturizer. And so we go through a long list of fragrance-free, dye-free hypoallergenic creams and ointments to allow it to kind of repair that barrier function. We use a lot of topical medications in dermatology, as I think everyone knows. And so the mainstays typically mild to moderate potency topical steroids to help control that inflammation once it occurs and giving families a good regimen to control it.

Once we get things started in clinic, in our services, oftentimes we'll have kids go back to their PCPs or see one of our nurse practitioners, once they're under better control. But I think we all, both our nurse practitioners and our physicians, see a huge range of eczema ranging from very mild to extremely severe that's really difficult to control even with the best of medicines.

Andrew Wilner: So if I understood, it's perfectly reasonable for a primary care physician to give it a shot. And if the treatment works, great. And if not, you would be sort of a second in line there for reinforcements to try something a little more complex. Is that right?

Brandon Newell: Absolutely. I mean, we spent a lot of time educating people who rotate with us and practitioners who we discuss with, how to start initial therapy there in clinic and kind of the first couple of steps to try. But definitely, if things don't act the way they should or don't respond well or if families feel very frustrated or therapy is not effective, then I think that's when we're probably more appropriate to step in. We're lucky in the fact that not only do we have five physicians who see patients, but we also have the same number of nurse practitioners. And so we're able to kind of spread that broad pediatric dermatology care across more patients than we could years ago. So, definitely, we try to encourage family practitioners, pediatricians to at least initiate therapy, and give it a good try.

Rebecca Flynn: If I could add to Dr. Newell there, one other reason we would like to see these patients in pediatric dermatology is if the primary care has attempted topical moisturizers and the standard topical steroid treatments and the patient fails to improve with those moderate potency topical steroids. Many primary care providers are not comfortable using stronger steroids, so that would be an appropriate time to go ahead and refer to pediatric dermatology. Or if the child has been using a topical steroid for more than three to four weeks, and we're not seeing any improvement, then we would also recommend the child follow up in pediatric dermatology.

Other situations as well, if the child needs extensive, maybe non-steroid prevention to prevent the flares or maybe has severe enough atopic dermatitis that they require a biologic treatment or potentially even further testing for allergic contact dermatitis, those are all great reasons to come to pediatric dermatology.

Andrew Wilner: Are there resources available for primary care providers to help them with these common dermatologic problems?

Rebecca Flynn: There are a lot of associations that you can use to have dermatologic conditions, resources for families. There's a great app called Skin Advocate, that anyone can download and you can find the disease process that you're looking at like atopic dermatitis. And for atopic dermatitis, you'll find the National Eczema Association. There's an app for the National Eczema Association as well. But specifically for atopic dermatitis, for our primary care providers, there's a great journal resource and the summary guidelines of 2015 for our most recent guidelines.

But at Children's Mercy, we've also published a care process management plan online for atopic dermatitis. And essentially, you can access that online at childrensmercy.org. You can click on Healthcare Providers Evidence-Based Practice and choose Care Process Management. And this will take you into two algorithms, one for infected atopic dermatitis and one for non-infected atopic dermatitis. It's a really nice resource to know when to utilize topical steroids, the strengths of different topical steroids and which one to use on which area of the body. Maybe when to hold the topical steroids. It also will give guidance with photos, for infections, whether that could be viral or bacterial, when to utilize topical antibiotics or maybe oral antibiotics are warranted, and also a picture summary for the severity of atopic dermatitis. If you don't see this every day, like Dr. Newell and I do, sometimes it's hard to know just how bad atopic dermatitis can be. So online is a nice resource that primary care providers can use to help guide their treatment for the patient with atopic dermatitis from mild to severe. So if it is that mild to moderate atopic dermatitis, those old tried and true methods with topical steroids and moisturizers might be all that's required managed by the primary care provider. Or if it is one of those more severe atopic dermatitis patients, they might need a referral to dermatology and explore the possibility of biologic medications to control that severe atopic dermatitis.

Andrew Wilner: Wow. It sounds like a lot of hard work went into developing that resource. That's fantastic. Well, we're running out of time. Dr. Newell and Nurse Practitioner Flynn, is there anything else you'd like to add?

Brandon Newell: You know, I think one thing that we always encourage our rotators to do when they're out in the real world practicing is to have a couple of good references for pediatric dermatology at the ready. And nowadays with iPads and iPhones, you can have several reputable pediatric dermatology books available at your fingertips. And so, it only takes a few minutes to look ahead and kind of read through on a patient who you're expecting to see for atopic dermatitis, just kind of see what overall is done so you can kind of keep up-to-date and offer that family some reassurance on the majority of the common stuff that we see in clinic could easily be handled by a primary care provider.

And, I think families really appreciate it when primary care providers take that extra step to learn about a pediatric skin condition. Maybe it's something very rare that they have never seen before. But I think those families really appreciate the providers who take that extra moment or step to at least familiarize it, so that they're not such a strange diagnosis in their clinic. And many of our general pediatricians will pick up these rare conditions and contact us. And so we really value the support of primary care providers in taking care of our patients because ultimately they're their patients.

Andrew Wilner: Well, that's fantastic. Well, that's all for now, Dr. Newell and Nurse Practitioner Flynn. Thanks for this informative discussion and joining me on Pediatrics In Practice.

Brandon Newell: Thank you very much.

Rebecca Flynn: Thank you.

Andrew Wilner: This has been Pediatrics In Practice with Children's Mercy Kansas City. Please remember to subscribe, rate and review this podcast and all the other children's mercy podcasts. To learn more about pediatric dermatology at Children's Mercy, please visit childrensmercy.org. I'm your host, Dr. Andrew Wilner. Thanks for listening.