Diagnostic concordance between pediatric emergency department physicians and dermatologists in a tertiary hospital in Mexico.

BACKGROUND AND OBJECTIVES: Skin diseases are a common reason for emergency department (ED) consultations; however, few studies have focused on pediatric patients. Diagnostic consistency between ED physicians and dermatologists varies from 43% to 58%, meaning many patients seeking emergency care may receive incorrect diagnoses and treatments. We aimed to determine the diagnostic concordance between ED physicians and pediatric dermatologists. METHODS: We conducted a prospective study including all pediatric patients (<18 years) who were seen for a skin condition at the ED from December 1, 2017, to June 1, 2018, and consented to participate. We classified diagnoses according to their etiology. Patients were diagnosed by ED trainees and attending physicians, followed by blinded pediatric dermatology trainees and attending physicians. We evaluated concordance using Fleiss's kappa coefficient (κ) with a 95% confidence interval. We further stratified the data by level of training. RESULTS: We included 185 patients. Inflammatory conditions were the most common reason for consultation, followed by infections; 10 patients required hospitalization. Concordance between diagnoses given at the ED and at the dermatology clinic was moderate (κ 0.472, 95% CI: 0.389-0.455) with 62.7% agreement. Concordance between different diagnostic categories was lowest for autoimmune disorders and drug reactions (κ 0.392 with 95% CI: 0.248-0.536 and κ 0.258 with 95% CI: 0.114-0.402). CONCLUSIONS: Diagnostic concordance between ED physicians and dermatologists was moderate and differed according to training level and diagnoses. Dermatological education for ED providers, specifically focusing on autoimmune disorders and drug reactions, may improve diagnostic accuracy and patient care.

The Skin Microbiome of Patients With Atopic Dermatitis Normalizes Gradually During Treatment.

Background: Atopic dermatitis (AD) is characterized by an altered skin microbiome dominantly colonized by S. aureus. Standard treatment includes emollients, anti-inflammatory medications and antiseptics. Objectives: To characterize changes in the skin microbiome during treatment for AD. Methods: The skin microbiomes of children with moderate-to-severe AD and healthy children were investigated in a longitudinal prospective study. Patients with AD were randomized to receive either standard treatment with emollients and topical corticosteroids or standard treatment with the addition of dilute bleach baths (DBB) and sampled at four visits over a three-month period. At each visit, severity of AD was measured, swabs were taken from four body sites and the composition of the microbiome at those sites was assessed using 16S rRNA amplification. Results: We included 14 healthy controls and 28 patients. We found high relative abundances of S. aureus in patients, which correlated with AD severity and reduced apparent alpha diversity. As disease severity improved with treatment, the abundance of S. aureus decreased, gradually becoming more similar to the microbiomes of healthy controls. After treatment, patients who received DBB had a significantly lower abundance of S. aureus than those who received only standard treatment. Conclusions: There are clear differences in the skin microbiome of healthy controls and AD patients that diminish with treatment. After three months, the addition of DBB to standard treatment had significantly decreased the S. aureus burden, supporting its use as a therapeutic option. Further study in double-blinded trials is needed.