A New Look at Atopic Dermatitis Management: Fresh Approaches for Primary Care - Episode 3
Determining Atopic Dermatitis Severity in Clinical Practice
A panelist discusses how diagnosing and assessing atopic dermatitis across diverse skin types in primary care requires visual familiarity, patient-reported outcomes like itch severity, and practical tools such as body surface area and Investigator’s Global Assessment, emphasizing that effective management depends on combining clinical observation with patient experience.
The speaker highlights the challenge of diagnosing atopic dermatitis (AD) across diverse skin types, particularly in patients with darker skin where the morphology can differ significantly from classic presentations seen in lighter skin. They encourage clinicians to seek out educational resources and clinical images to build visual familiarity with varied presentations. Diagnosing AD in primary care is also hampered by common obstacles like limited time, lack of dermatology access, and the wide differential diagnosis. These issues are not unique to primary care—they affect dermatologists too—making it crucial to perform full-body exams when possible and recognize that patients rarely present as textbook cases.
In evaluating severity, the speaker introduces various clinical tools used in dermatology research, like the IGA (Investigator’s Global Assessment), EASI (Eczema Area and Severity Index), and SCORAD. While these tools are helpful in clinical trials, they are often too complex for routine primary care use. Instead, the speaker advocates for practical measures such as tracking body surface area (BSA) and implementing the NRS (Numerical Rating Scale) for itch, a simple questionnaire on a 0-10 scale about itch severity in the past week. This one measure can give critical insight into a patient’s experience, as AD often involves severe itch even when the skin looks only mildly affected. Likewise, clinicians are encouraged to also consider skin pain, which affects a large subset of patients and can significantly impact quality of life.
For real-world practice, combining the IGA and BSA offers a feasible and informative way to assess disease severity. The IGA provides a general impression of lesion severity, while BSA can be measured using the rule of nines or the more precise palm method—with the patient’s palm equaling 1% of their body surface area. A palm-tracing trick is suggested for easier visualization. The speaker emphasizes that patients with extensive involvement (eg, ≥20% BSA) often require systemic or biologic treatment, not just topicals. The speaker concludes with a personal anecdote illustrating how visual assessment alone can mislead; a patient they believed had improved based on appearance hadn’t experienced any symptomatic relief, underlining the importance of incorporating patient-reported outcomes into care.
