Dr. Siegfried:I am sure you see lots of eczema, psoriasis, atopic dermatitis and contact dermatitis. How do you distinguish between all of these diagnoses?
Dr. Cordoro: Distinguishing between atopic dermatitis and psoriasis in very young and actually even older children can be really difficult. The two often overlap. In my observation, sometimes I find myself diagnosing eczematous psoriasis or psoriasiform eczemas, really a hybrid between those two diagnoses. Like you — you’re an expert clinician — I’ll try to use cutaneous clues to point me one way or another. Details about lesional morphology; distribution; special sites; what’s the overall state of the skin; are they widely xerotic or are they not; is there gluteal involvement? And if the family history and medical context and so forth doesn’t help me, I really don’t routinely perform biopsies to sort it out, because fortunately the basic management approach is similar for both conditions. Certainly atopic dermatitis far exceeds the prevalence of psoriasis but sometimes I do find it to be very challenging to disentangle the two, and I am not sure how relevant it is at the earliest stages in the youngest kids.
Dr. Siegfried: Would you agree that contact dermatitis often complicates atopic dermatitis and psoriasis?
Dr. Cordoro: Absolutely. I think differentiating atopic dermatitis from contact dermatitis is one of the most difficult clinical problems I face. Oftentimes I just allow some intellectual flexibility to think there is probably an overlap here, I’m going to treat for a period of time as I would for atopic dermatitis, and then if it evolves in a characteristic way or doesn’t respond to treatment, I’ll pursue patch testing if I remain suspicious for contact dermatitis.
Check out part two of this three part series: Pediatric psoriasis, eczema:Triggers and therapies
Dr. Siegfried: For kids whose primary skin disease you think is more psoriasis than eczema, do your initial treatment recommendations differ?
Dr. Cordoro: I think the only significant difference initially is that I’ll spend a lot more time on the importance of the concepts of gentle skincare, the skin barrier and preserving and restoring the barrier in kids with atopic dermatitis. I think that’s the significant difference. In terms of selecting a treatment regimen, it’s very similar with a few exceptions — like including a vitamin D analog for psoriasis that we wouldn’t use for atopic dermatitis. With every child that I treat with psoriasis I discuss the importance of keeping the skin hydrated with a good emollient to prevent trauma and friction which prompts spread of disease via koebnerization.
If there’s overlap, I think the more complicated conversation to have with parents is explaining the natural history of two diseases. Sometimes it is difficult to get parents to understand the reason that I can’t be specific right away and the possibility of an evolving treatment plan. That can be tricky when you are trying to earn parent’s trust as a clinician.