Expert Perspectives in the Management of Pediatric Atopic Dermatitis - Episode 9
Raj Chovatiya, MD, PhD; Brittany G. Craiglow, MD; and Peter A. Lio, MD, highlight challenges physicians face with the available atopic dermatitis treatments for pediatric patients.
Raj Chovatiya, MD, PhD: Before we jump into some of those newer therapies that are evolving, I want to ask you both about some of the challenges pediatric patients face in particular when it comes to some of the treatments we have right now, with both oral and topical treatments, kind of your classics. I’m thinking about topical corticosteroids, and then from an oral standpoint, thinking about methotrexate and cyclosporine as well. I’ll give the topical one to you, Britt, first. Tell me about some of the problems you feel that you face in terms of adherence, ease of application, and use and burden associated with current topical therapies.
Brittany G. Craiglow, MD: Probably the biggest thing we face is steroid-phobia, right? Unfortunately, that gets perpetuated a lot by pediatricians. Parents have been told don’t use too much of it. I think that’s one of the things I spend the most time on. I say, “Look, this is OK. I would never give you something that wasn’t safe, and that I wouldn’t give my child. This is important because it actually may save us in the long run.” I think we do have all these fancy new therapies, but like Dr Lio said, topical steroids have been around, and they remain the mainstay of therapy. I think a lot of patients can be well-controlled with them if used appropriately.
I see a lot of patients coming in, and I will say, “OK, we’re going to do use medicine called triamcinolone,” and they say, “Oh, we already had that.” OK, how did you use it? So getting the history from the patient and asking, “How big of a tube did you have?” They maybe had a 15-g tube, and they’re covered. How did you use it? “Well, I used it for a few days.” A lot of patients, I tell them, “You had the right ingredients, but you had the wrong recipe.” I will tell them, “I am giving you a jar of this medicine. This is my way of saying this is OK. And I want you to use it. You’re going to use it for 2 weeks straight, even though Johnny’s probably going to look better in a few days, and we’re going to put that fire out.” Finding an analogy, like what you’ve been doing is like pouring water on the fire. You’ve been making it better, but as soon as you stop, it comes right back. Oftentimes, you get these kids to clear and they stay clear longer, you save them a lot in the long run. I think getting over that fear and having people understand how they’re meant to use these things, and that it’s not usually this willy-nilly thing until they are on a maintenance regimen, that’s really important.
I think older kids just don’t like the way the topical feels. Corticosteroids, like I mentioned before, if you don’t like grease, you’re not going to use an ointment. Some patients really like that, but for other patients, it sticks to their clothes, they look shiny, and it’s gross. With the parents, it’s ruining their furniture. All these little things; when I was a resident I remember thinking why can’t anyone just do what I ask them to do? It’s because they have a real life. So making sure they’re using things appropriately, again, sorting out what’s going to work for them. We have stinging and burning sometimes, that tends to less from corticosteroids and more with other things that we’ll talk about later. And also time. Sometimes we have families where there’s a single parent, and maybe they leave before the kids get up, so they don’t have time to put the stuff on, so sometimes I’ll write a note for the daycare staff to do it, or whatever. Again, is this plan reasonable for you, and if it’s not, are there ways we can tweak it so that it can happen?
Raj Chovatiya, MD, PhD: Yes, I think that this whole concept of adherence, there’s a lot of power in this, right? Because we always think about it as compliance, but compliance is such a patriarchal way of thinking about it. In many ways, it’s about what we can do to try to keep people wanting to use the therapy they’re using. To your point, ointments aren’t always the end-all and be-all. In fact, systematic reviews suggests that maybe they aren’t in that sense. There’s a nice emolliating property to them, but bottom line, if someone uses the medication, odds are that they’re going to get better, if it’s something they actually want to use. I think that a lot of adherence, when this has been looked at, particularly in psoriasis literature, less so in eczema, at best in the real world, we’re talking about 40%, maybe 50% at best. So you’ve got to assume already the moment that somebody is probably leaving you, no matter how good of a job you did, they’re not executing your beautiful golden plan to fruition.
It’s one of those things that Peter harped on before. There’s a lot of education, and reeducation, and reviewing that comes with these visits, trying to get people to feel on top of what they’re doing and why they’re doing it. You’re almost like a life coach or a motivational coach in some sense. I feel like with a lot of my patients with chronic eczema, I’m not changing the plan all that much, but I’m still seeing them relatively frequently because I’m reminding them that we’re doing this, you can do it, this is what you want to do again. Largely, that’s another one of the things that makes the disease challenging. It’s not like I throw an antibiotic on it and it’s gone, the infection is gone, done deal. But rather, it’s the chronicity, it’s like a big idea.
Transcript edited for clarity