"If there’s one thing I hope clinicians take away, it’s this: When a patient with AD walks into your clinic, it might feel like just another rash on the schedule. But for them, it could be the reason they don’t leave the house."

Mona Shahriar, MD

Mona Shahriari, MD: I was very privileged to speak today on the psychosocial burden of atopic dermatitis. A lot of times, as clinicians, we focus on objective skin scores—achieving a certain EASI score or an IGA score—but the reality is, the skin doesn’t always tell the whole story. This disease has a multidimensional burden that goes far beyond what we can see or what the patient can see. That hidden burden is something we have to keep in mind every time we care for someone with AD.

There are a few key points I wanted to highlight. First is the idea of the hidden burden of atopic dermatitis. That includes itch, sleep disturbance, the financial impact, the mental health toll, effects on quality of life, and what’s known as cumulative life course impairment. That last one refers to how small but repeated disruptions—missing school, being embarrassed at a social event, changing what you wear—can add up over time and fundamentally alter a patient’s life trajectory. Because of that, there are two things I believe are essential.

First, we have to listen to our patients—really listen—at every single encounter. What might feel like just a few extra minutes to us can mean the difference between a patient feeling heard and trusting us, versus walking out feeling dismissed or hopeless. Second, when we’re assessing disease severity, we need to go beyond just looking at the skin. Ask about itch. Ask about sleep. Ask about mental health.

PC: Would you provide a few examples of the types of questions you ask?

Shahriari: I routinely ask questions like, “Having eczema can sometimes make people feel down or anxious—do you ever feel that way?” or “Is there anything you’re not doing because of your eczema?” These kinds of questions give us critical insight into the lived experience of the disease and help redefine what adequate control really means. So even if their skin looks better on follow-up, I don’t stop there. I’ll say, “Your skin looks clear—but are you happy? Is there still something you’re avoiding? Are you making clothing choices because of your eczema?” That gives us the context to decide whether the current treatment is truly working for that patient—or whether we need to make a change.

PC: How would you summarize your key message for primary care clinicians who treat individuals with atopic dermatitis?

Shahriari: For primary care physicians, the main message is this: AD is common, and the most common form is mild. So when they see it in practice, the assumption is often, “It’s just eczema, and the patient will grow out of it,” or “We’ll prescribe a steroid cream and it’ll get better.” And for many patients, that’s true. But for 30% to 40% of people with AD, that’s not the case. It’s not just eczema. They may not grow out of it. And the cream won’t be enough. So yes, try topical therapy—primary care is the first line of defense—but keep a low threshold for referring to dermatology. Because beyond what’s visible on the skin, the psychosocial burden—sleep loss, itch, anxiety, depression—is weighing on that patient, and they deserve a more comprehensive approach.

PC: During your session you related a case of a tragic outcome in a young woman with AD. Would you describe what happened?

Shahriari: I shared in my talk that one of my patients died by suicide. She had tried everything—topicals, orals, injectables. But she was bullied, and the way her skin felt and looked was unbearable to her. Her mother told me that despite all the treatment we had offered, she had simply had enough. That experience completely changed the way I practice dermatology.

Like many of us, I wasn’t trained in mental health. But in dermatology, we’re dealing with visible disease. That can be a double-edged sword. On one hand, because patients see their condition, the psychological burden is heavier. On the other hand, because they see improvement, successful treatment can be empowering. But we can’t overlook the mental health layer. I now work closely with psychologists and psychiatrists in my community. I screen every patient for mental health concerns, regardless of disease severity. Even if it’s mild AD, I want to catch any psychosocial issues early—because I’m often the only provider they’re seeing. That gives me a unique opportunity to recognize the second layer of disease and intervene before it leads to something more serious, including suicidality.

PC: If you give this presentation next year, what do you hope will have changed in the approach to treatment of AD?

Shahriari: One moment during the session really struck me. I asked the audience how many were familiar with the term cumulative life course impairment. Only 3 or 4 hands went up. That was eye-opening. I hope that after this session, more clinicians understand the long-term impact of AD. It’s not just a childhood disease. It’s not a short phase we treat and then forget about. These seemingly small challenges—like what you wear, what activities you avoid, what you miss out on—can build up and reshape someone’s entire future. That’s why early and comprehensive treatment matters.

If there’s one thing I hope clinicians take away, it’s this: When a patient with AD walks into your clinic, it might feel like just another rash on the schedule. But for them, it could be the reason they don’t leave the house. It could be the reason they don’t fall in love. It could be the reason they stop dreaming. Taking the time to ask the right questions, to understand the full burden of disease, and to start effective treatment—those things can genuinely transform lives.

Mona Shahriari, MD is an assistant clinical professor of dermatology at Yale University School of Medicine in New Haven, CT and co-founder of Central Connecticut Dermatology in Cromwell, CT

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