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The First 4 Visits When Treating Spongiotic Dermatitis, With Matthew Zirwas, MD
Zirwas outlines a 4-visit approach to diagnosing spongiotic dermatitis, helping dermatologists manage uncertain rashes more effectively.
Diagnosing spongiotic dermatitis relies on ruling out other dermatologic diseases. At the 2025 New Wave Dermatology meeting in Aventura, Florida, Matthew Zirwas, MD, a dermatologist at Bexley Dermatology, broke down what the first 4 visits for diagnosing spongiotic dermatitis should look like.
HCPLive sat down with Zirwas at the meeting to discuss these 4 visits, what dermatologists should do in situations where a patient has a non-specific rash, and when a wood lamp should be used to find the area to scrape in scabies.
“Whenever a new patient presents with spongiotic dermatitis, it can be overwhelming because we're so used to thinking about it in terms of: what are all the different things that could be doing this? Could it be contact dermatitis? Could it be atopic dermatitis? Could it be scabies? Could it be CTCL? Could it be dermatitis unspecified? What the heck is going on?” Zirwas said. ‘It really helps to have an almost algorithmic approach where you say, ‘Okay, first visit,’ and this is really the way that I think about it.”
Breaking the steps into 4 visits helps make the diagnosis more manageable, easier to see. During the first visit, Zirwas said you should assume your patient has contact dermatitis and get them away from any potential contact allergen, such as soaps or moisturizers. A patient should be treated as if they do have this contact dermatitis, whether that is with a topical or systemic steroid.
Patients could be treated with either clobetasol/moisturizer mix QD M-F, moisturizer only on Saturday and Sunday; 720 fexofenadine in the morning, consider 20 mg cetirizine in the evening; strontium cream or pramoxine cream for PRN use; and oral ceramide, oral probiotic (10 Strain), and melatonin 5-10 mg. You should see this patient anywhere between 4 to 8 weeks later to see if the medication improved their symptoms.
“If they are like, ‘Oh my God, it all cleared up. I don't even need to use that cream anymore.’ Great, it was contact DERM,” Zirwas said. “You can decide if you want to patch tests in to try and figure out what it was, or if you want to just let them continue to use low allergenicity products.”
Zirwas said you could consider tapering cetirizine or making steroid topical PRN if a patient does well after the treatment regimen.
However, if a patient is not dramatically better at that second visit, then you should assume the patient has atopic dermatitis and treat accordingly. Patients could be treated with mirtazapine 15 mg qhs if they want a sleep aid and duloxetine 30 mg qhs if they don’t need help with sleep. Zirwas recommends stopping topical steroids and antihistamines. Dermatologists should explain that mirtazapine, an old antidepressant, is not for depression but for itch nerve endings. During his presentation, Zirwas said mirtazapine was the most effective oral medication he has seen for itch.
If treatment for atopic dermatitis did not work by the third visit, 3 – 4 months later, that is when you may consider dermatologic conditions, such as unusual contact dermatitis, scabies, or CTCL. You could also switch a patient from mirtazapine to duloxetine or vice versa. You could also consider a commercial tanning bed (3-5 times a week for 20 visits) or in-office NBUVB. Patients who are getting better could go to a commercial tanning bed 1 – 2 times a week, long-term.
At this point, Zirwas said you should strongly consider a biopsy or a comprehensive patch test and then wait for the fourth visit. If the biopsy does not show CTCL or scabies, you should assume the patient has atopic dermatitis again and try alternative atopic dermatitis. You should also stop mirtazapine or duloxetine and consider gabapentin or pregabalin.
“We can only really be sure about what type of dermatitis it is by seeing what results in the patient getting better,” Zirwas said. “And so, [during] each of those visits, there's a different [one] we're going to try. We're going to try this if that didn't work, we're going to try this. If that didn't work, we're going to try this….it really does make for the most efficient way to conduct the visits and get the patients better.”
Relevant disclosures for Zirwas include Galderma Laboratories, L.P, Regeneron Healthcare Solutions, GENZYME CORPORATION, Arcutis Biotherapeutics, Lilly USA, Novartis Pharmaceuticals Corporation, Dermavant Sciences, LEO Pharma, Verrica Pharmaceuticals, Incyte Corporation, AbbVie, and PFIZER.
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