The pattern is familiar: an adult carrying a label of atopic dermatitis for years, through topical steroids, then a calcineurin inhibitor, then a systemic agent, still not clear. The reflex is to escalate again.
Today's Good Practice Statement makes the alternative explicit. Failure to respond to optimised treatment is itself a diagnostic finding, and the differential includes conditions with entirely different management: cutaneous T-cell lymphoma, allergic contact dermatitis, scabies, psoriasis. Some are dangerous to keep treating as eczema — mycosis fungoides in particular can be masked and even accelerated by immunosuppression.
So before adding the next agent, revisit the basics: what has actually been biopsied, has patch testing ever been done, has scabies genuinely been excluded, and does the distribution still fit. Where specialist access is limited, the biopsy and a careful contact history are the two steps with the highest yield.
- Treat non-response as a diagnostic finding, not a dosing problem
- Consider cutaneous T-cell lymphoma, contact dermatitis, scabies, psoriasis
- Immunosuppression can mask and worsen mycosis fungoides
- Where access is limited, biopsy and contact history give the highest yield
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