Practical Management of Atopic Dermatitis: Nurse Practitioner and Physician Assistant Perspectives - Episode 3

Atopic Dermatitis: Early Referral to Dermatology Clinics

July 31, 2021
Melodie Young, MSN, RN, ANP-C, Mindful Dermatology and Modern Research Associates

,
Douglas DiRuggiero, DMSc, PA-C, Skin Cancer and Cosmetic Dermatology Center

,
Keri Holyoak, PA-C, MPH, Dermatology Center of Salt Lake

,
Susan Tofte, DNP, MS, FNP-C, Oregon Health & Science University

Recommendations on educating primary care physicians about atopic dermatitis and the importance of early referral to dermatologists.

Melodie Young, MSN, RN, ANP-C: At what point do you think patients begin to seek care? We know care can be delivered at the pediatrician, at the allergist, at an urgent care center, in dermatology, and there’s a tremendous number of patients who go to the emergency room when they just can’t take it anymore. What has been your experience, Douglas?

Douglas DiRuggiero, DMSc, PA-C: I see all of the above. The most recent study done 2 years ago shows that only 19% of pediatricians refer patients in the first year, who have severe atopic dermatitis [AD]. They don’t get referred soon enough, in our opinion. But I get a lot of referrals from urgent care, and some are from parents who go online and do their own research and say, “I’m tired of using topical steroid creams or being told that my child has persistent impetigo and is always given antibiotics.” I practice in the area with good pediatrics and people that appreciate our care. I see a lot of 3- to 6-monthers that are getting diagnosed early on. But on the flip side, we see Medicaid patients, and we’re the only Medicaid practice in all of northwest Georgia. We see a lot of patients who come in very late that don’t have that level of care at home. I saw a 15-year-old yesterday with severe atopic dermatitis who had never seen a physician for it before and finally was able to get on Medicaid. I saw her for the first time ever, so she was completely naïve to treatment.

The word needs to get out to our primary care on what atopic dermatitis is and that we have new, exciting treatments that can change lives, beyond topical creams. Get [the patients] into our offices early. We must educate our primary care [physicians] so they know what they’re dealing with. It’s not just impetigo and an allergy to soaps, even though those things can play a role. This is a more complex, multifactorial disease that we get to be the point on. We partner with rheumatologists because it can affect the joints in psoriasis. But here, they’re partnering with allergists and us. I don’t know if you have things to add to that. 

Susan Tofte, DNP, MS, FNP-C: Go ahead, Keri.

Keri Holyoak, PA-C, MPH: I agree with Douglas. Patients come in when they’re desperate for answers and for relief. They’re usually in a flare, when their skin is insanely itchy, and they’ve exhausted the options and are wanting more answers. They’re tired and worn out. I’ve seen most of my cases are moderate. They have been suffering for too long. I’d like to think that our AD patients are being seen by dermatology providers, but the majority of them—let’s be real—it’s likely that primary care and pediatricians are diagnosing [more cases] and treating more of our atopic dermatitis patients.

Melodie Young, MSN, RN, ANP-C: Susan, you’ve spent decades advocating for eczema and you’ve been president of the National Eczema Association. I’m sure you’ve heard a lot of stories. If you could speak about trying to help patients navigate their way: When they finally are looking for the provider that’s going to give them some expertise in this disease, how do you help them as an organization?

Susan Tofte, DNP, MS, FNP-C: I agree with Douglas and Keri; patients are seen in urgent care clinics and emergency departments because they’re so desperate to get the help they need. Unfortunately, my biggest pet peeve is when patients go to an urgent care clinic and are given a 15-g tube of a topical steroid to treat whole-body eczema. There’s nothing that aggravates me more because those poor patients are left hanging. They become so desperate that they fight their way to get to a specialist. Unfortunately, we are bound by managed care rules and all kinds of preauthorizations and things where patients can’t get in. Patients become desperate enough to push their way in and offer to pay, self-pay, or whatever it might take. These patients are mismanaged or misdiagnosed in those urgent care [clinics] and emergency rooms, and often will be given a course of Prednisone, just to get them in and out quickly, or an injection of Kenalog, which is not good long-term management.

I do feel it is our job as dermatology providers to help educate primary care [physicians] and pediatricians because those patients can be managed in those specialty areas, but they need to have the toolbox to be able to know how to treat them appropriately.

Melodie Young, MSN, RN, ANP-C: Yes, and there are school nursing associations that are other opportunities for care.

Melodie Young, MSN, RN, ANP-C: Thank you for watching this HCPLive® Peer Exchange. If you enjoyed the content, please subscribe to our e-newsletters to receive upcoming peer exchange segments and other great content right in your in-box.

Transcript Edited for Clarity

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