The Financial and Emotional Costs of Severe Atopic Dermatitis: A Case Study
A 53-year-old man presented to the emergency department (ED) with a 1-day history of chills, malaise, fatigue, and severe exacerbation of his lifelong atopic dermatitis (AD). The patient reported shaking chills after an “itching frenzy” that resulted in diffuse excoriations and bleeding over his extremities and torso. Vitals upon presentation were: temperature 99.6°F, blood pressure 139/91 mm Hg, heart rate 96 beat per min, respiratory rate 25 breaths per min, and white blood cell count 15,800/mm3 meeting sepsis criteria. Physical exam was notable for severe lichenified and excoriated bleeding plaques on face, trunk, arms, and legs with concomitant serous drainage from these plaques. The patient was admitted for presumed bacteremia likely from a skin source, secondary to his poorly-controlled AD. Dermatology was consulted for advice on management of his skin disease.
This patient was well known to the dermatology department due to his frequent office visits and inpatient hospitalizations for his AD disease exacerbations. Over the past 6 months, the patient presented to the ED 4 separate times resulting in 3 separate hospitalizations for complications of his severe AD. These included exfoliative erythroderma, cellulitis, and sepsis secondary to methicillin-resistant Staphylococcus aureus bacteremia. In the past 6 months, his inpatient admissions totaled 28 nights and 31 days. The average cost for 96 hours for diagnosis of sepsis ranges from $8000 to 11,000 (USD) in Forsyth County, NC. Using this information, this patient’s inpatient costs over the past 6 months could total from $56,000 to $77,000.
Prior attempted therapies for this patient included topical corticosteroids, oral antihistamines, gabapentin, oral and intramuscular corticosteroids, methotrexate, mycophenolate mofetil, infliximab (Remicade), and adalimumab (Humira).
Management of this patient has been complicated by multiple other chronic comorbidities including Crohn disease with ileostomy, coronary artery disease, and alcohol and tobacco abuse. Depression and lack of psychosocial support has caused difficulty with maintaining a successful treatment plan for this patient.
While this case is certainly on the extreme end of adult AD, it does highlight several key points related to difficulties experienced in chronic management of severe AD—chronic relapsing-remitting disease process, suboptimal medications, and lack of adherence.
Discussion on page 2