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Engaging the Patient in the Management of Their Disease

Dawn M.R. Davis, MD, highlights ways dermatologists and other providers can engage patients with atopic dermatitis in tracking their disease severity. Dr Davis is a professor of pediatric and adolescent medicine and professor of dermatology as well as division chair of clinical dermatology at Mayo Clinic in Rochester, MN.


Dr Davis: It's important to have a thorough and crucial conversation with your patient and their family unit or caregiver when a diagnosis of atopic dermatitis is made. While patients, of course, would prefer that it be a short, time‑limited condition that can be easily fixed with a pill or cream, preferably a one‑time‑use, as we all know, that is not practical.

So, I discuss with them the concept that now that they have atopic dermatitis, they will likely need to adapt some basic things in their activities of daily living to help their skin. The analogy I use is that typically when a patient gets diagnosed with diabetes, they have to be mindful of their weight. They have to be mindful of their diet, then they may need intervention such as insulin or other medications.

Then I tell them, similarly, when patients have atopic dermatitis, they now need to adapt their activities of daily living, that that becomes their new normal, that sensitive skin care is indefinite, and that intervention and proactive treatment with first- and second‑line therapies by prescription or in the office comes and goes as the eczema waxes and wanes.

I also like to explain that even though the skin is an organ that you can see, it is not uncommon to have dryness and itch that you can't necessarily see with the naked eye that is still active dermatitis or consequences thereof, that you don't necessarily have a very frank erythematous, weeping, crusting rash to have an atopic dermatitis flare.

In my skin of color patients particularly, I like to explain that at times, it is very difficult to see the early onset stages of inflammation based on their skin type. I typically talk with all patients, regardless of skin type, about the phenomenon of postinflammatory pigment change and how it can be either hypopigmented or hyperpigmented and in some patients can be both.  Particularly in skin of color patients, this can be of great concern. Sometimes, regardless of patients, there are questions, sensitivities or perceptions that go along with postinflammatory pigment change where it is presumed to be different than eczema or perhaps hard-to-distinguish, active inflammation and inflamed skin vs postinflammatory pigment change.

It is very important to educate and empower the patient, and have them understand that they are the focus and the center of the care team. What I like to say is that if we're caring for you, you are driving your eczema bus, not me. I'm simply in the passenger seat helping you drive. It's my obligation and pleasure as your physician to understand who you are, what your lifestyle is like, and how I can best help you so that I can put a smorgasbord or array of options in front of you, talk to you about the benefits, the risks, the side effect profiles, the logistics, and the potential glitches of each therapeutic option, and then let you make an educated decision based on who you are and what works best for your life on which treatment options you would like to try. When I see you on follow‑up, because you've been given a list of all the treatment options at this point, if one thing isn't working, we can nuance it and move on to a different treatment or adapt it slightly to meet your needs.

I always make sure or try to remember to connect the patient with patient advocacy groups and resources because I find that to be very helpful. Patient advocacy groups can offer a different approach and community to the patient. They often have blog sites or frequently asked questions. The patient finds that as a second resource and a source of reprieve and may feel more comfortable discussing certain topics with the community rather than with the physician.

It's important over time for the patient and the provider to develop a cohesive, mutually beneficial relationship because we are here to help our patients, answer their questions, and help them and their to skin feel better.

With regards to atopic dermatitis, it really is a care team model, whole person care with the patient at the center and focused as our point of discussion. The National Eczema Association CUBE‑C project, the Coalition United for Better Eczema Care, discovered that it takes several visits, three to four on average, for patients to feel comfortable with eczema with regards to its pathophysiology, sensitive skin care regimen, escalated treatment options, and their specific care routine to have all their questions and concerns addressed before they feel confident in their skin, pun intended.

So, please be mindful to educate your patients about the fact that atopic dermatitis is not simply a skin disease, will require more than one visit and likely more than one modality and treatment approach to find resolution with sensitive skin care, avoidance of allergens and irritants, moisturization always as a baseline, and then other prescription modalities and interventions in the dermatologist's office as first, second, and systemic advanced line therapies thereafter.

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