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Dr Shi: How to Look Beyond the Skin in AD Diagnosis

The following is a transcript of the video Diagnostic Challenges: Looking Beyond the Skin with Vivian Shi, MD, FAAD. Dr Shi is an associate professor of the department of dermatology at the University of Arkansas for Medical Sciences in Little Rock.

To watch her explain why managing atopic dermatitis is similar to playing a piano, click here!


DR ShiDr Shi:  I always say eczema is more than skin‑deep. We mentioned that it's associated with other conditions like asthma and food allergies and hay fever, but even going beyond that, it's the mind and body interaction, and the interference, that many patients and their families get. Ultimately, that will affect their quality of life.

For example, it really puts a lot of stress on the family. Taking care of an eczema child is a full‑time job. Just from the work that we do with parent groups, some of them actually have to take time off work or quit their job altogether to take care of a child with moderate to severe eczema. That workload is added exponentially when they have more than one family member with atopic dermatitis.

There's also the mental health perspective on the patient and the family. We know that older atopic dermatitis individuals are more likely to have anxiety and depression, and the work that they need to take care of their skin also decreases their productivity in school and work, and that may indirectly lead to financial issues and career development and career choices even.

In younger children, we know that there is a behavioral or cognitive interference, and it's a wide spectrum. Kids with eczema, because of lack of sleep and chronic itching, they can range anywhere from having more withdrawn type of behavior to hyperactivity, even to some extent so‑called disobedience, were they're commonly mislabeled as troublemakers in school, but in reality, it's the disrupted sleep and lifestyle due to their eczema that's changing their behavior. These are things that we need to be cognizant about as care providers to help parents and/or community understand the troubles and the challenges they're facing.

Managing eczema is like playing piano. The entry level is easy; you just put your finger on the key, and you're good. It's so easy to say, to give you a cream and moisturize, and you're good,  but when you really get into mastering eczema management, it's complicated. It's like playing a concerto.

I would say the most important thing is partnership with the patient and their family. They are the experts in taking care of eczema, not me. They live in their skin every day, and they are the true teachers. I get the most valuable information from them.

The challenge is when they come to a dermatologist's office every so often, every other month, or even every 3 months, and for those who live further away to come to the eczema center, sometimes it's only once a year. How do we, as providers, get to be there without physically being there is the challenging part to understanding the remissions and flares of what worked and what didn't work.

Thank goodness that we have a lot of trackers nowadays to help patients and family keep diaries and set reminders for treatments, and one of them is actually developed in collaboration with the National Eczema Association called EczemaWise. Patients and family can actually enter their severity, triggers, and document their usage of medications, and then it can have a pretty good summary for the doctor when they do meet.

That leads to the era of shared decision‑making. Traditionally the doctor says, "This is what you're going to do, and you're going to do it." It's very authoritarian. More and more so, the shared decision model is where it's a partnership, where patients and caregivers as well as doctors both have input on both the treatment goals and designing the treatment plans, so everybody is an equal team player. That's been shown to have led to better relationships between the patients and the provider, better understanding of the challenges that both sides face, and set equal ground expectations. It's decreased misunderstanding and improved adherence, and ultimately, outcome. I think this is one of the hardest part to do in my practice because it takes a lot of time and will lead to partnership, to get to know the family and the patient well.

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