What Do Clinicians Mean When Submitting a Biopsy as “Rule Out Eczema”

Background: “Eczema” encompasses many dermatological conditions and usually manifests with spongiosis histologically. Dermatopathologists often receive biopsy specimens with requests to “rule out eczema.” However, this broad term is limiting and lacks the necessary clinical context for precise diagnoses. Objective: This study explored the conditions implied by “rule out eczema” when rendered by clinicians and whether they regard it as synonymous with atopic dermatitis or other spongiotic conditions. Understanding this distinction is vital for guiding appropriate treatment which differs among disparate conditions appearing similar histologically. Method: 63 clinicians (54 dermatologists, 5 physician assistants, 4 nurse practitioners) completed a web-based questionnaire. Participants identified conditions considered when requesting to “rule out eczema,” who completed requisition forms, and whether they modify automated EMR phrases to specify these conditions. Results: 83% (52/63) included atopic dermatitis in the differential diagnosis, with “rule out eczema” also referencing nummular eczema (65%), dyshidrotic eczema (54%), contact dermatitis (51%), neurodermatitis (22%), and seborrheic dermatitis (14%). Other conditions included mycosis fungoides, psoriasis, and tinea infections. Most forms were completed by medical assistants (51%) or dermatologists (43%). 81% were modified from the suggested EMR diagnosis before submission. Conclusion: Because “rule out eczema” is nonspecific and conditions may not be readily distinguished with histology alone, it’s recommended that the phrase be discarded in favor of specifying which disorder the clinician is presumptively diagnosing clinically. Because nonspecific phrases such as “dermatitis unspecified” generated by EMR programs are of limited value, it is not recommended to provide these options for clinicians when submitting biopsy specimens.