Expert Perspectives in the Management of Pediatric Atopic Dermatitis - Episode 2

Atopic Disease Heterogeneity and Physician Awareness

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Experts in dermatology comment on the heterogeneity of atopic dermatitis and how this affects clinical practice decisions, patient quality of life, and disease burden.

Raj Chovatiya, MD, PhD: I love that you use the word heterogeneity because that’s the core principle of disease that makes it so exciting and interesting on our standpoint—to treat, see, understand, and learn about. But that can also make it difficult in terms of thinking about that patient aspect of the burden. We oftentimes think about the disease as mild, moderate, or severe, and they’re very clean buckets. Some of the signs you’ve told us about allow us to make some of those judgments. But when you think about all the different heterogeneous clinical domains beyond the skin signs, when you think about symptoms, quality-of-life burdens, comorbidities, all things you touched on, a lot of this can change what you might see on the skin—mild, moderate, or severe—and that can have a lot of big implications on treatment, which we’ll talk about in a bit.

I want to come back to you, Britt. Maybe you can tell us a little about not exact numbers but what your feelings on the prevalence of atopic dermatitis in pediatric patients? You mentioned that it’s 1 of the things you commonly see in dermatology. Is this really common? Is this something that a lot of pediatric practitioners outside dermatology are seeing as well? What are your thoughts on what happens in the long run as these kids grow up?

Brittany G. Craiglow, MD: It’s common, especially in the younger population. Up to a quarter of patients or kids, or even more, will have AD [atopic dermatitis]. Depending on where you live and the access to dermatology, a lot of these kids are still with their pediatrician. Some are unfortunately not being appropriately managed, or there’s this idea that they’re going to grow out of it, so they tolerate it. Maybe they’ll grow out of it, but it’s not OK for someone to be miserable. As the treatment landscape is evolving, part of our job as dermatologists is to educate. We have more tools now. When you sent kids to dermatology before, they weren’t coming back with a lot that was helpful or different from what you could offer. But all of a sudden, we have more options. This is a disease that kids don’t have to live with anymore.

The way we think about it needs to shift a little bit too. To your point about mild, moderate, and severe, we have to remind ourselves that just because someone is not erythrodermic, doesn’t mean they’re not miserable. We see the spectrum. Just because patient A doesn’t look as bad as patient B, that doesn’t mean it’s not having a big impact on their quality of life. It’s all about the patient experience. Now we have things to offer them that have a better safety profile. When our choice was cyclosporine or mycophenolate, maybe we tolerate the higher disease severity because we’re weighing risk and benefit, but now we need to shift our framework because we have these options. Many people aren’t being appropriately treated and honestly, in kids, their trajectory is sometimes altered by this. It’s important that we step up and educate and treat our patients a little more aggressively.

Raj Chovatiya, MD, PhD: How often are you seeing that, Dr Lio? Some parents or caregivers don’t want to treat their child, and they hope they’re going to outgrow the disease or that it’s just a little skin thing they’ll get over?

Peter A. Lio, MD: I definitely see that a fair amount. Usually, they’re not dismissing the disease, but they’re afraid of the potential side effects of medications. They recognize that it’s a huge burden. It affects quality of life, and that’s usually why they’re showing up. At the same time, there are many trepidations about starting some of the medicines, which admittedly can sound pretty off-putting. Even with topical corticosteroids, our old friends since the 1950s, if you start reading about what they can do, sometimes there’s a hesitation to start therapy. I often try to convey that even though many patients will get better in time, and certainly some will outgrow their disease, an awful lot of patients still maintain it. In particular, it seems as though the more severe patients will continue to suffer from the disease even into adulthood. I have a whole group of patients who are bitter because everyone throughout their young lives said, “Don’t worry, you’ll grow out of this.” Now they’re in their 20s, 30s, or 40s and saying, “Here I am decades later, and I’m still miserable with this disease.”

I’m a big proponent, as Britt was saying, of treating early and aiming for excellent disease control. Not only do you automatically win by getting people better, but you take away that suffering, pain, disruption of sleep—all those pieces. There may be a hidden benefit, which is that we may be able to modify the course of the disease. If we can do that—not only atopic dermatitis but maybe some of the allied and comorbid allergic-type diseases, those comorbid conditions—that could be a huge win for all involved.

Transcript Edited for Clarity