Multidisciplinary Approach to Eczema Treatment

Individuals with eczema often also have asthma, hay fever, sleep disorders, and even psychological issues such as depression, and the eczema can exacerbate these associated medical problems (Figure 1). 

The Northwestern Multidisciplinary Eczema Center was developed to address all of these concerns in one place, with a multidisciplinary team comprising dermatologists, allergists, neurologists, sleep specialists, and specialized nurses (Figure 2).

“The classic situation for many with eczema is that they are chronically itchy and sleep deprived due to their eczema and allergies. The result is that their professional lives and personal relationships begin to suffer,” said Jonathan I. Silverberg, MD, PhD, MPH, director of the Center and assistant professor of dermatology, medical social services and preventive medicine, Northwestern University Feinberg School of Medicine. “This multidisciplinary approach allows patients to receive personalized care to meet their individual needs,” he said.

Dr Silverberg conceived the idea for a multidisciplinary approach to treatment of eczema patients during his dermatology residency, as a result of his clinical and research experiences. “Taking time to talk to my patients and understand the sequelae of their skin disease opened my eyes to the massive patient-burden of atopic dermatitis. It also made me recognize that proper management of all the direct and indirect effects of atopic dermatitis often requires expertise beyond the scope of typical dermatology residency training,” said Dr Silverberg. “I found these associations with atopic dermatitis fascinating and began to study them. It quickly became clear to me that there was a whole world of previously unrecognized comorbid health disorders that occur in atopic dermatitis.”

This realization led Dr Silverberg to propose and establish the Northwestern Multidisciplinary Eczema Center. “Patients with atopic dermatitis are quite complex. A multidisciplinary approach is often required to treat the ‘whole patient,’ improve health outcomes, reduce polypharmacy, and improve communication among providers,” he said.

Benefits
The multidisciplinary approach is beneficial on several levels. “First, a multipronged treatment approach is required to adequately address inflammation, skin barrier, and itch; and, second, patients with atopic dermatitis have a number of less commonly recognized symptoms of their skin disease, including very poor sleep and symptoms of depression and anxiety,” explained Dr Silverberg. He noted that iit is imperative to address these symptoms to improve treatment outcomes in atopic dermatitis, and added that this may require engagement of sleep medicine and mental health colleagues.

In addition, patients with atopic dermatitis commonly have one or more allergic disorders, such as allergic contact dermatitis and rhinoconjunctivitis, which may trigger flares of their skin disease. “Adequate treatment of such allergic disorders may be required to improve their skin disease,” said Dr Silverberg.

Another less obvious benefit, he pointed out is that the multidisciplinary approach “improves communication among our dedicated group of providers,” and that this “allows for a collective decision about optimal approaches, reduces polypharmacy issues such as competing and/or conflicting medications, and improves patient adherence and patient safety.”

Now in its third year, the Northwestern Multidisciplinary Eczema Center includes clinicians from dermatology, allergy/immunology, neurology, and sleep medicine, as well as research personnel from Northwestern Medicine’s clinical trials unit. “By having providers from multiple specialties collaborating in the same clinic, we are able to achieve control of severe refractory skin disease, improve quality of life, simplify treatment approaches, and improve patient safety,” said Dr Silverberg.

He added: “We have a close relationship with our colleagues in psychiatry, gastroenterology, and endocrinology, among other specialties.”

The program uses a variety of validated instruments to screen for comorbidities of atopic dermatitis, said Dr Silverberg. Patients who come to the Center are first seen by a dermatologist and then take an evidence-based questionnaire to help detect if they have additional conditions such as asthma, allergies, and sleep disorders. Dr Silverberg pointed out that the questionnaire can uncover additional health concerns that are related to the eczema that may not even be recognized by the patient.

Patient benefits were recognized early in the program’s existence. “We have seen remarkable treatment success in controlling patients’ skin disease and improving overall health outcomes. Patients with controlled disease are no longer itchy and are sleeping well for the first time in decades. They are able to get back to work and enjoy life,” said Dr Silverberg. He explained that extensive benchmark data is continuously collected and used to improve delivery of care.

“We have seen improved overall severity of atopic dermatitis with fewer flares and hospitalizations, improved quality of life, and improved patient satisfaction scores,” he said.

Integration of clinical trials into the practice setting is another important segment of the multidisciplinary treatment program. “Participation in clinical trials has offered many patients access to cutting-edge treatments for atopic dermatitis when they have failed existing treatments,” Dr Silverberg explained. A study demonstrating the superiority of the multidisciplinary vs conventional care model is planned for publication.

Figure 2. An illustration of a multidisciplinary eczema team approach.

Overcoming Obstacles

Bringing the Northwestern Multidisciplinary Eczema Center to fruition had its challenges. “First, it was essential to find the right clinician partners to work with,” said Dr Silverberg. “I have been fortunate to have some amazing collaborators.” Second, he pointed out, “There were a number of logistical issues that needed to be worked out, including having enough clinical space and dealing with billing for various specialties.”

Finally, he said, “It is important to recognize that the multidisciplinary approach may not be a cash cow in current payer models. However, as new payment models emerge based on quality of care, reimbursements for a multidisciplinary approach will likely increase.”

To successfully launch the clinic, a significant amount of training was required for nurses, call center personnel, billers, and other ancillary staff, according to Dr Silverberg. “For example, we have developed scheduling blocks in order to allow sequential visits with providers and our nurses have been trained in skin-prick testing, patch testing, and assessment of sleep disturbance, among other things,” he said.

Since the Center’s inception, a number of changes have been made to the original plan to adjust for patient and/or practitioner experiences. “We had to make a number of minor adjustments to improve efficiency and workflow,” explained Dr Silverberg, “and we plan to incorporate a psychologist into the multidisciplinary setting.”

The program’s success has stimulated a number of research studies into the burden of atopic dermatitis and novel treatment approaches, according to Dr Silverberg. “It’s been tremendously satisfying for me to be able to bring outstanding care to our patients, who in turn have expressed their pleasure with the approach, and their appreciation that they can simultaneously see their specialists instead of having to schedule separate appointments on different days. It’s a game-changer for them, both from a satisfaction and disease response standpoint,” he said.

The multidisciplinary model has shown itself to be effective beyond eczema. Northwestern Medicine has established several other effective multidisciplinary clinics including those for psoriasis/psoriatic arthritis, cutaneous T-cell lymphoma, and rheumatology-dermatology. “These each provide ‘one-stop shopping’ for patients and improve inter-provider communication so that treatment decisions are made with all providers present,” said Dr Silverberg.

Individuals with eczema often also have asthma, hay fever, sleep disorders, and even psychological issues such as depression, and the eczema can exacerbate these associated medical problems (Figure 1). 

The Northwestern Multidisciplinary Eczema Center was developed to address all of these concerns in one place, with a multidisciplinary team comprising dermatologists, allergists, neurologists, sleep specialists, and specialized nurses (Figure 2).

“The classic situation for many with eczema is that they are chronically itchy and sleep deprived due to their eczema and allergies. The result is that their professional lives and personal relationships begin to suffer,” said Jonathan I. Silverberg, MD, PhD, MPH, director of the Center and assistant professor of dermatology, medical social services and preventive medicine, Northwestern University Feinberg School of Medicine. “This multidisciplinary approach allows patients to receive personalized care to meet their individual needs,” he said.

Dr Silverberg conceived the idea for a multidisciplinary approach to treatment of eczema patients during his dermatology residency, as a result of his clinical and research experiences. “Taking time to talk to my patients and understand the sequelae of their skin disease opened my eyes to the massive patient-burden of atopic dermatitis. It also made me recognize that proper management of all the direct and indirect effects of atopic dermatitis often requires expertise beyond the scope of typical dermatology residency training,” said Dr Silverberg. “I found these associations with atopic dermatitis fascinating and began to study them. It quickly became clear to me that there was a whole world of previously unrecognized comorbid health disorders that occur in atopic dermatitis.”

This realization led Dr Silverberg to propose and establish the Northwestern Multidisciplinary Eczema Center. “Patients with atopic dermatitis are quite complex. A multidisciplinary approach is often required to treat the ‘whole patient,’ improve health outcomes, reduce polypharmacy, and improve communication among providers,” he said.

Benefits
The multidisciplinary approach is beneficial on several levels. “First, a multipronged treatment approach is required to adequately address inflammation, skin barrier, and itch; and, second, patients with atopic dermatitis have a number of less commonly recognized symptoms of their skin disease, including very poor sleep and symptoms of depression and anxiety,” explained Dr Silverberg. He noted that iit is imperative to address these symptoms to improve treatment outcomes in atopic dermatitis, and added that this may require engagement of sleep medicine and mental health colleagues.

In addition, patients with atopic dermatitis commonly have one or more allergic disorders, such as allergic contact dermatitis and rhinoconjunctivitis, which may trigger flares of their skin disease. “Adequate treatment of such allergic disorders may be required to improve their skin disease,” said Dr Silverberg.

Another less obvious benefit, he pointed out is that the multidisciplinary approach “improves communication among our dedicated group of providers,” and that this “allows for a collective decision about optimal approaches, reduces polypharmacy issues such as competing and/or conflicting medications, and improves patient adherence and patient safety.”

Now in its third year, the Northwestern Multidisciplinary Eczema Center includes clinicians from dermatology, allergy/immunology, neurology, and sleep medicine, as well as research personnel from Northwestern Medicine’s clinical trials unit. “By having providers from multiple specialties collaborating in the same clinic, we are able to achieve control of severe refractory skin disease, improve quality of life, simplify treatment approaches, and improve patient safety,” said Dr Silverberg.

He added: “We have a close relationship with our colleagues in psychiatry, gastroenterology, and endocrinology, among other specialties.”

The program uses a variety of validated instruments to screen for comorbidities of atopic dermatitis, said Dr Silverberg. Patients who come to the Center are first seen by a dermatologist and then take an evidence-based questionnaire to help detect if they have additional conditions such as asthma, allergies, and sleep disorders. Dr Silverberg pointed out that the questionnaire can uncover additional health concerns that are related to the eczema that may not even be recognized by the patient.

Patient benefits were recognized early in the program’s existence. “We have seen remarkable treatment success in controlling patients’ skin disease and improving overall health outcomes. Patients with controlled disease are no longer itchy and are sleeping well for the first time in decades. They are able to get back to work and enjoy life,” said Dr Silverberg. He explained that extensive benchmark data is continuously collected and used to improve delivery of care.

“We have seen improved overall severity of atopic dermatitis with fewer flares and hospitalizations, improved quality of life, and improved patient satisfaction scores,” he said.

Integration of clinical trials into the practice setting is another important segment of the multidisciplinary treatment program. “Participation in clinical trials has offered many patients access to cutting-edge treatments for atopic dermatitis when they have failed existing treatments,” Dr Silverberg explained. A study demonstrating the superiority of the multidisciplinary vs conventional care model is planned for publication.

Figure 2. An illustration of a multidisciplinary eczema team approach.

Overcoming Obstacles

Bringing the Northwestern Multidisciplinary Eczema Center to fruition had its challenges. “First, it was essential to find the right clinician partners to work with,” said Dr Silverberg. “I have been fortunate to have some amazing collaborators.” Second, he pointed out, “There were a number of logistical issues that needed to be worked out, including having enough clinical space and dealing with billing for various specialties.”

Finally, he said, “It is important to recognize that the multidisciplinary approach may not be a cash cow in current payer models. However, as new payment models emerge based on quality of care, reimbursements for a multidisciplinary approach will likely increase.”

To successfully launch the clinic, a significant amount of training was required for nurses, call center personnel, billers, and other ancillary staff, according to Dr Silverberg. “For example, we have developed scheduling blocks in order to allow sequential visits with providers and our nurses have been trained in skin-prick testing, patch testing, and assessment of sleep disturbance, among other things,” he said.

Since the Center’s inception, a number of changes have been made to the original plan to adjust for patient and/or practitioner experiences. “We had to make a number of minor adjustments to improve efficiency and workflow,” explained Dr Silverberg, “and we plan to incorporate a psychologist into the multidisciplinary setting.”

The program’s success has stimulated a number of research studies into the burden of atopic dermatitis and novel treatment approaches, according to Dr Silverberg. “It’s been tremendously satisfying for me to be able to bring outstanding care to our patients, who in turn have expressed their pleasure with the approach, and their appreciation that they can simultaneously see their specialists instead of having to schedule separate appointments on different days. It’s a game-changer for them, both from a satisfaction and disease response standpoint,” he said.

The multidisciplinary model has shown itself to be effective beyond eczema. Northwestern Medicine has established several other effective multidisciplinary clinics including those for psoriasis/psoriatic arthritis, cutaneous T-cell lymphoma, and rheumatology-dermatology. “These each provide ‘one-stop shopping’ for patients and improve inter-provider communication so that treatment decisions are made with all providers present,” said Dr Silverberg.