The patient with autism: Dermatologists need to be prepared

0315-Oza

Vikash S. Oza, MD

One in 68 children is diagnosed with autism, and many of those children will either have skin conditions or behaviors that cause them to rub or pick at their skin. In short, dermatologists need to be prepared to treat children with autism and work with families faced with special needs.

“This is something we’re going to see more and more, and families expect their physicians to have an understanding of this condition,” Vikash S. Oza, MD, said March 6 in his presentation “Improving the Care of the Autistic Patient in Dermatology” (U069). He is an assistant professor of pediatrics and dermatology at the Ronald O. Perelman department of dermatology at New York University School of Medicine.

Autism is five times more common in boys than girls, and the condition is a neurodevelopmental disorder with deficits present prior to age 3. It is most commonly recognized in three “spheres”:

  • Restricted interests and stereotyped behavior, such as repetitive behaviors, insistence on sameness, obsessive interests, and lack of imaginative play
  • Communication, such as language delay, difficulty with conversation, and impaired non-verbal communication
  • Socialization, such as disinterest in social interaction, avoidance or resistance to physical contact, or not responding to comfort under duress

“Many children find comfort in their self-stimulating behaviors,” Dr. Oza said. “It may be a sign that a child is having an issue in the current clinic environment.”

Many health care professionals are familiar with definitions of autism as defined in DSM-IV, but that definition has changed with the move to DSM-5. Terms such as “Asperger syndrome” and “pervasive developmental disorder” are now labeled “autism spectrum disorder” (ASD).

“Within ASD, there is great variability. There are children at high-functioning levels who are very intelligent, and then 20 percent with ASD are non-verbal,” Dr. Oza said.

Dermatologists can expect to deal with genetic and behavioral dilemmas in children with ASD. Patients with ASD who are verbal report that they “get bombarded with multiple sensory inputs and have a hard time making sense of them,” he said.

This can be seen in tactile integration, where children are hypersensitive, hyposensitive, or sensation-seeking. Hypersensitive children may overreact to light touch or avoid some textures, such as a clothing label. A hyposensitive child may have an increased tolerance to pain. Sensation-seeking children may enjoy deep pressure or spinning.

Another issue that can be linked to skin conditions is diet. Children with ASD may like food based on texture, color, and taste, and families may adopt diets based on what the children like, Dr. Oza said. Many patients with ASD have increased gut permeability and have gluten- or casein-free diets, and specific food restrictions.

Patients also may present with what appear to be rashes or other skin conditions linked to chronic rubbing or picking at the skin. “Keep in mind, ‘is this self-induced?’” he noted.

To deal with these challenges, physicians should prepare to be as flexible as possible during exams, and be mindful that the clinic environment can affect the behavior of a patient with ASD. Because children may have trouble processing the environment and an exam, it helps to be verbal and explain actions before doing anything.

“Children do well when they know they will be moving from one activity to the next, so pointing this out can help,” Dr. Oza said, adding that families with a child with ASD are familiar with this approach.

Finally, it is important to recognize that children may have idiosyncratic reactions to medications.

“Be flexible about the vehicles you use,” Dr. Oza said, adding that oils or foam-based products may be more accepted. “Also, don’t overwork the parents. It’s a complex situation, so be sensitive to those issues when caring for a child.”

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