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Atopic Dermatitis Signs and Symptoms for Referral: Physical and Emotional Expertise
Primary care is the ideal setting for management of atopic dermatitis, but certain scenarios, both physical and psychological, call for expert referral.
Knowing when to manage atopic dermatitis (AD) in primary care and when to refer is crucial for optimal outcomes. While the majority of AD can be managed by frontline clinicians, certain clinical scenarios warrant referral to dermatology, mental health services, or both.
Referral to Dermatology
In an interview with Patient Care, Mona Shahriari, MD, assistant clinical professor of dermatology at the Yale School of Medicine, outlined several factors that should prompt consideration of referral from primary care.2
Disease-Related Factors
- Moderate to severe disease that hasn't responded adequately to appropriate topical therapy
- Uncertain diagnosis or atypical presentation
- Need for systemic therapy (biologics, JAK inhibitors, immunosuppressants)
- Chronic hand eczema or other AD variants
Impact-Related Factors
- Quality of life significantly impaired despite treatment
- Patient or family expressing significant distress about the disease
- Sleep significantly disrupted by symptoms
- Social or occupational functioning impaired
- Patient requesting specialty evaluation
According to Shariari and other experts, the threshold for referral should be lower for adolescents given their particularly high burden and vulnerability during this developmental stage.
Referral to Mental Health Services
Some patients need mental health support in addition to dermatologic care; Shariari toplined those situations as well.2
- Screening positive for depression or anxiety (PHQ-9 ≥10, GAD-7 ≥10)
- Any expression of suicidal ideation (requires immediate assessment)
- Significant functional impairment beyond what skin severity would predict
- Social isolation or avoidance behavior
- Family struggling to cope with caregiving demands
- History of trauma related to disease experience (bullying, medical procedures)
The Collaborative Care Model
Optimal care for AD with significant psychological burden requires coordination between dermatology and mental health services. Consider:
- Warm handoffs - Direct communication between providers to ensure patient follows through
- Shared treatment goals - Both skin clearance and psychological well-being as outcomes
- Simultaneous treatment - Addressing both dimensions concurrently rather than sequentially
- Family-centered approach - Including caregivers in treatment planning, especially for pediatric patients
Harvard child psychologist Jennifer LeBovidge, PhD, emphasizes that addressing mental health shouldn't wait until skin disease is controlled: "Don't wait for one to improve before addressing the other."7 Both dimensions deserve simultaneous attention, she stressed.
