Perioral dermatitis can look a lot like atopic dermatitis. For primary care clinicians, the similarity in presentation can create challenges in providing the right treatment and knowing when a patient needs to be referred to a dermatologist.
The two conditions look similar; both present with itchy, swollen rashes. But atopic dermatitis can be located anywhere on the body, whereas perioral dermatitis is usually concentrated around the mouth, nose, and eyes. Treatment differs as well, which is why correct diagnosis is crucial.
Multiple types of dermatitis can dupe clinicians into a guessing game that can lead to inappropriate prescriptions and a clinical puzzle for patients. Dermatologists say that a few basics can help primary care clinicians discern the difference and know when to refer.
Topical steroids — treatments applied directly to the skin — can help improve atopic dermatitis but will only make perioral dermatitis worse. Steroids are also ill-advised for rosacea, which is often confused with atopic dermatitis and causes reddened skin and a rash on the nose and cheeks.
“With perioral dermatitis and with rosacea, if you treat with topical steroids, it may initially get a little bit better, or at least some of the symptoms may,” with less itchiness and burning, said Shari Lipner, MD, PhD, a dermatologist at Weill Cornell Medicine in New York. But the root of the skin the problem goes unsolved, and the medication makes the conditions last longer.
Lipner said that over-the-counter topical hydrocortisone could exacerbate the conditions. Through referrals, Lipner has seen patients with severe cases of perioral dermatitis that could have been addressed sooner.
“When they get to me, it’s often a lot worse than it was initially, before any treatment, and it’s very frustrating for the patient,” Lipner said.
Patients may experience distress when they learn that more suitable treatments were readily available with a proper diagnosis. Lipner generally prescribes the topical antibiotic metronidazole to treat perioral dermatitis, or the oral antibiotic doxycycline for more severe cases. Perioral dermatitis symptoms usually resolve quickly with proper treatment, Lipner added.
Knowing When to Refer
If a patient says they have a rash, Emily Milam, MD, a dermatologist at NYU Grossman School of Medicine in New York, advises primary care clinicians to first determine the cause. If the rash is skin irritation, it could be treated by switching antiperspirants or advising patients to properly bathe affected areas. What may appear to be a rash could be irritation from perspiration or other bodily fluids.
Milam said that if a rash seems especially sensitive to light or appears to be correlated with joint pain or fever, clinicians should refer patients to a dermatologist. Acne with scarring or with skin lumps and red bumps warrant a visit to the dermatologist.
The same is true for cases of severe eczema, as well as for psoriasis and vitiligo. Dermatologists are likely to have the most knowledge about biologic medications that could be appropriate for treatment in these cases, Milam said, but a primary care clinician could prescribe biologics if they feel comfortable doing so.
If atopic dermatitis, also known as eczema, is properly diagnosed, a primary care physician can advise a patient about how to treat it with over-the-counter medications, or prescribe appropriate drugs. For example, the National Eczema Association notes that both over-the-counter and prescription steroids can help improve eczema symptoms, adding that people should not use steroids longer or more often than advised.
But often, “dermatologists generally do not like any over-the-counter topical antibiotic,” such as Neosporin, according to Milam. These treatments can trigger the allergic reaction known as contact dermatitis, which means the patient will experience an itchy rash. Milam advised that primary care clinicians prescribe topical antibiotics when needed.
Primary care clinicians should use their own judgement on when to refer patients: No guidelines exist on the timeframe by which to decide that a treatment is faltering.
“If the treatment is not working despite the patient and clinician’s best efforts, it’s reasonable to refer to dermatology,” Milam said.
But What if You Can’t Refer?
Primary care clinicians may run into roadblocks in referring patients, such as not having any in their network, or patients may face months-long wait times. In the United States , there are only 3.4 dermatologists for every 100,000 people. People living in rural areas and those without health insurance are also less likely to see dermatologists.
“Demand for healthcare exceeds supply right now,” said Kent D.W, Bream, MD, a family medicine physician at the University of Pennsylvania in Philadelphia.
A decade ago, Bream helped launch a teledermatology program in partnership with the American Academy of Dermatology (AAD), focused on unhoused and other vulnerable populations in Philadelphia. These people were patients of primary care clinicians but faced a wait of at least 3 months for a dermatologist visit.
Before the teledermatology program was launched, there was no way to prioritize dermatology cases. That’s because the primary care clinician did not have access to dermatologists who could help them resolve some situations while referring out more challenging cases.
Through the AAD’s teledermatology program, which still exists today, a primary care or family medicine clinician in an underserved community can upload an image of a patient’s skin problem and receive a reply from a dermatologist within 12 hours. In-person dermatologist appointments are available as needed.
The utility of telemedicine is better recognized than it used to be.
“I do a lot of telemedicine, and often there’s a shorter wait,” Lipner said, adding that she began practicing telemedicine during the COVID-19 pandemic.
“It’s a game-changer,” making tasks like properly diagnosing perioral dermatitis easier, Lipner said. With a video consult or a good photograph of the affected area, a dermatologist can accurately spot perioral dermatitis and make sure the patient starts proper treatment right away.
Lipner, Milam, and Bream report no relevant financial relationships.
Marcus A. Banks, MA, is a journalist based in New York City covering health news with a focus on new cancer research. His work appears in Medscape, Cancer Today, The Scientist, Gastroenterology & Endoscopy News, Slate, TCTMD, and Spectrum.
Source link : https://www.medscape.com/viewarticle/dont-be-misled-proper-dermatology-diagnoses-crucial-accurate-2024a10001va?src=rss
Publish date : 2024-01-26 10:27:45
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