An Expert Nurse Practitioner & Physician Assistant Exchange on the Management of Pediatric Atopic Dermatitis - Episode 11
Alexa Hetzel, MA, PA-C, and Lakshi Aldredge, MSN, ANP-BC, DCNP, provide insight into emerging therapies and ongoing investigations in the management of pediatric atopic dermatitis.
Melodie Young, NP: Are any of you aware of the new topical therapies coming down the pipeline for pediatric populations? Have you looked at those at all yet?
Alexa Hetzel, MA, PA-C: Yes. Our office is in the clinical trial for topical tapinarof for AD [atopic dermatitis]. I have a 3-year-old [patient] who’s in this study, and he had about 80% BSA, had a 3 score on the PGA [Physician Global Assessment], and it was bad. Poor mom she was like, “My kid, I need help.” We put him in the study because, our office doesn’t take the insurance, but she brought him to us because his atopic dermatitis was so bad. A week later he was, I would say 60% better, it was incredible. He started singing Black Sabbath, and it was funny, he’s like, “I am Iron Man.” You could tell the mood of this child had changed completely from a week of topical therapy. It’s exciting to see all these different things that we have that are coming and actually work.
Melodie Young, NP: In dermatology, we know topicals. It’s been hard for us to get away from topicals, and now that we have topical options, it’s how much and how to use. We are trained for that, and we can teach our colleagues in pediatrics and allergy. We’ll definitely be speaking about that. Have any of you read or heard anything else about some of the other topical and systemic therapies being evaluated in the under-18 crowd? What does it mean to have more options? What do you think about having these additional options? Hopefully at least part of them will be available.
Lakshi Aldredge, MSN, ANP-BC, DCNP: It’s exciting because topical therapy has taken a huge backseat in the world of dermatology with the emergence of all the biologic therapy that has happened in the last 20 years. In the last 5 years we’ve had research studies and new agents in the topical realm, which has been exciting because not all patients need a systemic agent because they’re not necessarily moderate or severe but are starting to get there. For whatever reason, topicals seem to be the most appropriate option. It’s nice to have those agents. Alexa mentioned the aryl hydrocarbon receptor agonist as a topical target, which is exciting because it’s nonsteroidal and seems to have excellent efficacy with a very safe profile. We have several other topical treatments that are coming down the line, and we don’t know the target specifically because it’s a number in the research clinical trials, but nonsteroidal looking at more of the inflammatory markers and targeting the barrier disruption portion of pathogenesis.
It’s exciting to have this time in dermatology where there’s a resurgence, a renewed interest, in topical research studies. I’m grateful for pharmaceutical companies that are putting the time and effort into creating topical treatments because this is the bread and butter of dermatology. Topical management of skin conditions definitely has a place, not only in our hearts, but on our skin because it’s what we do well, and it’s what patients want because it provides almost immediate relief. As you mentioned, Mel, itch is the heartache of most dermatologic conditions, but also the pain that comes with ongoing scratching when you have deep excoriations, it can become secondarily infected and painful. To have both topical and biologic therapy that is emerging in the atopic dermatitis sphere is a win for both providers and patients and their families.
Melodie Young, NP: Dupilumab, as efficacious as it’s been, it doesn’t fix everyone, and it doesn’t fix everyone at a 100%. It’s incredibly effective and has changed so many lives, but we need more. I have adult patients who have not done as well on dupilumab as they needed to, and I have started them on some of these newer biologic agents and oral small molecule agents that have come into the market, and they are doing beautifully. We all know that this is a complex disease, and there’s no one therapy that’s going to be the end-all for every patient. In the clinical trials in dermatology, everything’s used as monotherapy. Occasionally you’ll get to use a low potency topical corticosteroid additionally with some of them, but it’s important if you want to clear a person and get them as best managed as possible to have a multitude of options to pick and choose from, so the more the better.
To try to interrupt, to have more agents come to the pediatric population, we want to see studies done as much as possible in adolescents and pediatric patients, with hope that the FDA will be favorable with helping to oversee that. I’d love to have more data about use in pregnancy. Again, we’re talking about drugs in adolescents, and to have more data about that, and more data in all the different races, ethnicities, and different populations of people we see. The better data we have, the better decision-making we can have, and better care we can provide.
Transcript edited for clarity