An adult whose presumed atopic dermatitis does not respond to properly optimised treatment may not have atopic dermatitis alone. A good practice statement on refractory adult atopic dermatitis, published in JAAD in August, supports diagnostic reassessment before moving to the next systemic.
The common alternatives are allergic contact dermatitis, scabies, tinea, drug eruption and, importantly in older adults with new-onset disease, cutaneous T-cell lymphoma.
- Check adherence and technique first; under-treatment is the commonest cause of apparent failure.
- Patch test for allergic contact dermatitis, including to topical treatments.
- Scrape for fungus and look for burrows.
- Biopsy adult-onset or atypical disease, especially with new onset after 50 or poor response to dupilumab.
Why it matters
Escalating immunosuppression for a missed contact allergy or lymphoma adds harm without addressing the cause.
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