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A Multidisciplinary Approach to Evaluation and Treatment of Atopic A Multidisciplinary Approach to Evaluation and Treatment of Atopic Dermatitis Mark Boguniewicz, MD,* Noreen Nicol, MS, RN, FNP,† Kim Kelsay, MD,‡ and Donald YM Leung, MD, PhD* Atopic dermatitis is a common, complex disease that frequently follows a chronic, relapsing course. The disease can impact the quality of life (QOL) of patients and families to a significant degree. Patients and caregivers may focus on unproven triggers at the expense of proper skin care. A multidisciplinary approach is needed to comprehensively evaluate triggers and response to treatment, address confounding factors including sleep disrup- tion, and educate patients and caregivers. Semin Cutan Med Surg 27:115-127 © 2008 Elsevier Inc. All rights reserved. topic dermatitis (AD) is a common, complex diseaseden thaton the patient, family, and12,13 Thus,society. a multidis- A frequently follows a chronic, relapsing course andciplinary re- approach is needed to comprehensively evaluate sults from as-yet incompletely understood interactionstriggers of and response to treatment, address confounding fac- genes and environment in susceptible individuals.1,2 Recent tors including sleep disruption, and educate patients and insights into AD have pointed to the role of abnormalitiesfamilies. in the epidermal barrier, although these abnormalities may be caused by both mutations of genes encoding proteins such as filaggrin,3 as well as modulation of epidermal protein Wholevels Are the Members of by Th2-type cytokines.4,5 In addition, patients with AD theap- Multidisciplinary Team? pear to have abnormalities in their innate immune6 response The model described is the Atopic Dermatitis Program (ADP) and can have abnormal immunologic responses to allergens at National Jewish Medical and Research Center in Denver, and microbial antigens.3,7 Colorado. The ADP has been in existence for more than 20 Although patients may have mild disease and appear to years, and 3 of the authors have worked together in this outgrow their AD, in some studies, a significant number of program for the past 18 years. Our team is composed of patients develop more severe or persistent8 Thesedisease. pediatric allergist-immunologists with extensive experience patients and their families may experience significant impair- in basic and clinical research in AD, a nurse practitioner/ ment in QOL.9 Childhood AD may have a greater impact on dermatology clinical specialist, pediatric psychiatrist, psy- health-related QOL than asthma, diabetes, enuresis, and cys- chologists, allergy-immunology fellows-in-training, physi- tic fibrosis.10 In addition, a significant number of patients cian assistants, nurse educators, child life specialists, a with AD go on to develop asthma and allergies and this im- creative art therapist, social workers, dietitians, and rehabil- portant association is often not explained to patients and itation therapists. Dermatologists are available for consulta- 11 Finally, AD places a significant economic bur- caregivers. tion i f diagnosist h e of AD is in question or alternative therapies, eg, phototherapy are being considered.phi- Our losophy of care is in keeping with our Center’s approach to *Division of Pediatric Allergy-Immunology, Department of Pediatrics,individualized Na- medicine, and patients undergo comprehen- tional Jewish Medical and Research Center and University of Colorado School of Medicine, Denver, CO. sive evaluation and treatment tailored to their needs and †Department of Nursing, National Jewish Medical and Research Center and goals of the patient. Our ADP provides single-day consulta- University of Colorado School of Nursing, Denver, CO. tions in addition to a multiple-day outpatient clinic visits or ‡Division of Pediatric Behavioral Health, Department of Pediatrics, National Day Program for more extensive evaluation, education, and Jewish Medical and Research Center and Department of Psychiatry, Uni- treatment. This unique program allows for comprehensive versity of Colorado School of Medicine, Denver, CO. Address correspondence to Mark Boguniewicz, MD, National Jewish Medi- evaluation and treatment of patients in an outpatient setting, cal and Research Center, 1400 Jackson Street, J310, Denver, CO 80206. typically over the course of 5 to 10 days. In this controlled E-mail: [email protected]. environment, patients and caregivers interact with members 1085-5629/08/$-see front matter © 2008 Elsevier Inc. All rights reserved. 115 doi:10.1016/j.sder.2008.05.001 116 M. Boguniewicz et al of the multidisciplinary team between 8 AM and 5 PM, as well Such critical education is increasingly difficult to accomplish as overnight, if necessary, especially when evaluating sleep in the typical clinic visit. Studies have shown that patients fail disturbance and response to interventions.14 Importantly, to receive adequate explanation of the causes of AD or are not patients and caregivers interact with other patients and fam- taught how to apply topical medications, even though in- ilies in formal and informal settings. The ongoing evaluation struction and practical demonstrations may be associated and response to therapy in the Day Program are reviewed in with dramatic improvement in the treatment outcomes.16 clinical review meetings with the patient/caregiver and Plan We use a multidisciplinary care approach, which includes of Care conference that involves input from the various ser- education and a stepwise approach to the management of AD vices. Rarely, patients may also be admitted as in-patients. similar to the approach to asthma. The National Asthma Ed- ucation and Prevention Program: Expert Panel Report 3, like our AD program, includes instructions for daily treatment, Who Are the ways to recognize and handle worsening disease, and empha- Patients That sizes the use of a stepwise approach for this chronic disease May Benefit from a using written action plans.17 This treatment model includes multiple educational strat- Multidisciplinary Approach? egies and requires that all members of the multidisciplinary Although AD patients of all severities could benefit from a team teach the same key concepts and reinforce the messages multidisciplinary approach, the current health care system being delivered to the patients and caregivers regardless of often creates roadblocks to such an approach. Patients who which strategy is incorporated. Strategies include one-on- are “failing” conventional therapy, those labeled as polyaller- one communication, direct demonstration with reinforce- gic (especially those believed to be allergic to multiple foods), ment, group discussions, classroom teaching, and written patients with recurrent skin infections or who are receiving materials, including an AD home care or AD action plan. frequent courses of antibiotics, patients with concerns about A critical educational strategy is direct demonstration of medication side-effects, patients whose disease is causing a proper skin care, which includes topical application tech- significant impact on their or their family’s QOL, and those niques and wet wrap therapy. Watching the patient’s or car- patients with a need for in-depth education are all candidates egiver’s current technique often reveals fundamental errors for multidisciplinary management. It is worth remembering that helps providers understand why a patient may not be that families may have different levels of tolerance for a dis- responding to therapy as expected. The following are 2 illus- ease; thus, this approach may benefit more than just severe trative examples of patients referred for treatment failure that AD patients. improved with appropriate review of their application tech- The patient and family with chronic AD have often seen niques and education. The first was a patient who failed multiple health care providers who may have given them hydration therapy, but observation revealed that a thick coat confusing or conflicting information, which sets up a cycle of of petrolatum was applied before soaking her skin, rather frustration and search for a straightforward solution to their than after the bath. The second patient was referred as a problem. Practitioners of unproven therapies may take ad- failure of topical corticosteroid therapy and was under using vantage of these patients, even promising a cure. Thus, it prescribed medicines demonstrated by both direct observa- becomes imperative to convey the message that at present, tion of application and by examining medicine tubes. A tube treatment is directed at levels of control, not a cure. The of medication, which should have lasted for 2 weeks, was still significant and sustained clinical improvement often ob- partly full after 3 months. served in the patients treated with a multidisciplinary ap- The patient or caregiver needs to understand details of the proach may be caused in large part by in-depth, hands-on treatment regimen to ensure compliance and improved clin- education, along with changes in environmental exposures, ical outcomes. Many patients and caregivers misunderstand reduction in stressors, and assurance of adherence with ther- the potency of topical corticosteroids. This results in the ap- apy. A high percentage of these patients experience signifi- plication of a high-potency corticosteroid (eg, beclometha- cant improvement even when treated with medications that sone dipropionate 0.05%) to an area of the body such as the previously were believed to be ineffective when the treatment face or axillae while using a lower-potency corticosteroid (eg, is integrated into a
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