When is It Time to Refer? A Dermatologist Considers Atopic Dermatitis Treated in Primary Care

Atopic dermatitis (AD) is one of the most common chronic skin conditions, affecting millions of all ages. With about 80% of patients managed initially in primary care and the limited access in many places to dermatologists, the role of the frontline clinicians in diagnosing and initiating treatment for AD is expanding.

Mona Shahriari, MD
Assistant clinical professor of dermatology
Yale University School of Medicine

In a recent interview with Patient Care,® dermatologist Mona Shahriari, MD, associate clinical professor of dermatology at Yale University School of Medicine in New Haven, CT, talked about the essential role played by primary care practitioners (PCPs), about new nonsteroidal topical treatments for AD and what PCPs should keep in mind when choosing a first-line treatment, and the indicators that signal when it’s time to consider specialist referral and systemic therapies.

The interview transcript has been lightly edited for clarity and length.

Patient Care: There are data that show approximately 80% of individuals with atopic dermatitis are diagnosed and treated in in primary care. Does that align with your experience?

Mona Shahriari, MD: Yes, it does. Our primary care colleagues are the first line of defense when it comes to any illness, but in particular, atopic dermatitis. That’s especially true given how challenging it can be to see a dermatologist in certain parts of the country, both in terms of geography and access and also being able to get an appointment. Many specialists are booked out for months and so many primary care practitioners are becoming more comfortable in diagnosing and treating skin disease. I know in my practice, when a primary care provider sends me a note that a patient needs to be seen urgently, we do accommodate them as quickly as we can compared to taking a call from the patient. When a primary care colleague calls, they have typically tried everything and yet the patient hasn’t made progress. “I need to phone a friend and have you see dermatology,” is their next step.

PC: What should a primary care clinician consider when choosing a first line topical treatment for atopic dermatitis? Is there some trial and error to the approach?

Shahriari: There could be some trial and error because of the familiarity some clinicians have with different topicals, and the choice can also be affected by what a clinician used most commonly during training—that can make a difference when you get out into everyday practice. But I think the most important features of a topical treatment are it should be effective, safe and tolerable, and in a formulation the patient likes. I also believe the treatment regimen should be simple. Sometimes a patient will end up with one topical for the face, another one for the body. They use this twice a day for the first 2 weeks, then transition to another topical Monday through Friday and only use the initial ones on the weekends. But if the disease comes back, you go back to the initial regimen.

Have we ever taken a moment to ask ourselves, “What are we asking our patients to do?” If I personally have trouble sticking to using my moisturizer twice a day, how can I expect my patient to do this complex regimen consistently and effectively? We need to keep in mind simplicity of the regimen. I would suggest that they receive one topical that they can use on any affected area, head to toe, without restrictions on the duration of use. That strategy sets them up for success.

PC: What are the signs or symptoms that you would say should indicate to a primary care clinician that it's time to make a specialist referral and potentially to consider systemic therapy?

Shahriari: Topical treatments for atopic dermatitis may simply not be feasible in the long term. If the skin clears on the topical, but as soon as they stop, the disease comes right back, we have to start thinking about other treatment. Or maybe the skin became clear on the topical, but the patient still has uncontrolled itch during the daytime, or maybe it even wakes them up at night. So it's really our job as clinicians to ask the hard questions, properly assess whether or not control of the disease is adequate on the topical treatment so that we avoid undertreatment and delays in initiating systemics. And I oftentimes recommend the Atopic Dermatitis Control Tool. It's 6 easy questions and take 30 seconds for the patient to complete. But, the bottom line is that if you see that the atopic dermatitis is not adequately controlled, that's a really easy button to press and say, "Hey, I'm going to send you to dermatology, because we can do better than this."

My take home message is that I've been using these next generation topical nonsteroidal medications in my daily practice, and I've really noticed a paradigm shift where I reach for these over my old reliable topical corticosteroids. So whether we're looking at efficacy, safety or simplicity of the regimen, these new topicals have really raised the bar in terms of what we can expect from topicals for AD in the year 2024. I do hope that primary care clinicians who are listening seriously consider including these agents in their atopic dermatitis toolbox, because they really have the potential to optimize the patient experience with their treatment as well as their disease.