A diagnostic checklist for generalized dermatitis

Abstract

Purpose: Generalized dermatitis (defined as histological spongiotic dermatitis affecting more than three anatomical areas of the skin surface) has many potential causes that mimic atopic dermatitis and contact dermatitis. If a treatable cause is missed, the patient may be treated with chronic immunosuppressive therapy that carries more risk than specific treatment for a disease mimicking dermatitis. Checklists have been shown to improve patient safety, primarily in procedural contexts. This work assessed the utility of a diagnostic checklist for subacute and chronic generalized dermatitis in patients who had not improved after at least 1 month of avoidance of contact allergens identified by comprehensive patch testing, if indicated. Patients and methods: Designed as a quality improvement project using Standards for Quality Improvement Reporting Excellence (SQUIRE) guidelines, a diagnostic checklist was used by the principal investigator for 1 year in a tertiary referral dermatitis clinic for patients without a confirmed cause for the dermatitis after two to three visits with the investigator. All patients had had diagnostic patch testing if indicated. Almost all had undergone skin biopsy by their referring provider. Fifteen patients met the criteria for inclusion in this study. Outcome measures included provider and patient perception of efficiency and/or confusion caused by the checklist. Length of time from the initiation of use of the checklist to final diagnosis was recorded. Additional diagnoses considered that were not included in the initial checklist were added to the checklist during the course of the study. Results: The checklist was useful in improving diagnostic efficiency (prompting consideration of diagnoses not otherwise considered upon initiation of the visit that resulted in a final plan of care) in these complex cases of recalcitrant dermatitis. Open utilization of the checklist by the investigator during the clinical encounter was well accepted by patients and families. Conclusion: Checklists can be useful for complex cognitive diagnostic work.IRB approval status: University Hospitals Cleveland Medical Center Institutional Review Board # 11-15-34.