An Expert Nurse Practitioner & Physician Assistant Exchange on the Management of Pediatric Atopic Dermatitis - Episode 4

Pediatric Atopic Dermatitis: Clinical Examination

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Melodie Young, NP; Alexa Hetzel, MA, PA-C; and Matthew Brunner, PA, discuss their approach to a clinical examination of patients with pediatric atopic dermatitis.

Melodie Young, NP: the common presentations, as Matt mentioned, are the places that we look. Alexa, tell me more about when you're doing the exam on the patient, they have on a diaper, what are some of the key findings, and where do you know to look to say, “Is this going to be an AD [atopic dermatitis], or is this going to be an acute rash?”

Alexa Hetzel, MA, PA-C: Depending on which age, if we're thinking diapers, I like to look everywhere; regardless I like to look everywhere, just to see how encompassing the rash can be. I look at the creases of the body, so the arms, neck, behind the legs, and in the groin. Those are things with the biggest spots that I look forward to seeing. Many pediatric rashes can also involve the complete trunk, so depending on if it's maculopapular, if it's more patch like. It's finding that differentiation between, and how scaly and dry. Those are the types of things that I look for.

Melodie Young, NP: What about the mouth, what's acute when you see the mouth of a child?

Alexa Hetzel, MA, PA-C: I always like to look at them too, because that gives them away, whether they're scratching or if they're licking their lips; things like that always give somebody away. Especially once you bring it up, they can't stop, when you look at the eyes how red and puffy they can be. Even with the mask, you can tell right away who's an atopic patient, versus who's not looking at their face sometimes.

Melodie Young, NP: And what about the hands on a child, I know that's also a cue. Matthew, what do you see?

Matthew Brunner, PA: I like to look at the dorsum interdigital. We're going to see a lot of erythema and scaling in those areas’ excoriations.

Melodie Young, NP: What about nail changes, sometimes you'll see that as well.

Matthew Brunner, PA: We can see hitting in the nails, and other nail fold changes. Sometimes you might get it confused with psoriatic changes in the nail, except for very rare, and you can see it in a small child, whereas atopic dermatitis is much more likely to be what you see with all those other factors that we mentioned. Lakshi, is there anything else that you want to add?

Lakshi Aldredge, MSN, ANP-BC, DCNP: Yes, Matthew brought up an excellent point, which is how to assess skin of color. It's important to understand that the manifestation of atopic dermatitis as those typically erythematous, lichenified with excoriations can be an issue. What you typically see in lighter skin tones, but in darker skin tones, it's important to look behind the ears and in the scalp. Especially on the eyelids and in the perioral area as well, for those darkened violaceous areas which you may not associate immediately with inflammation or atopic dermatitis. In chubby babies they tend to have, or maybe some adults, more folds that can often be misdiagnosed, especially in the diaper area as diaper rash and allergic contact dermatitis. Having patients regardless of the age dress in a gown, gives you the opportunity to assess all the skin for those classic atopic derm areas and lesions. It also gives you a sense of the moisturization pattern of the skin, so how hydrated are patients, do they have generalized cirrhosis which can make atopic dermatitis worse, looking at the nails, or any early nail changes that can be associated with atopic dermatitis. Also looking at the eyes and genital area and doing a full skin exam gives you the opportunity to look for moles and be a conscientious derm provider.

Transcript edited for clarity