An Expert Nurse Practitioner & Physician Assistant Exchange on the Management of Pediatric Atopic Dermatitis - Episode 6
Matthew Brunner, PA, shares his advice for engaging pediatric patients with atopic dermatitis in their treatment and disease care, while Lakshi Aldredge, MSN, ANP-BC, DCNP, discusses her treatment protocols.
Melodie Young, NP: We were talking about that patient-centric approach, and when they get older, patients will take a bigger role. That can be frustrating, trying to get a teenager to do more, and that preteen and child to do it themselves. There’s sort of a battle that will happen between who’s going to do it and who’s going to be responsible for it. Does anybody have any hints on getting the child more involved, and becoming more patient centric, where you’re talking with the child, encouraging and teaching them, instead of always talking to mom, dad, or grandparent?
Matthew Bruner, PA: I always use myself as analogy, because I’m a patient with atopic dermatitis [AD]. I try to identify with the patient, I explain to them what my skin looked like when I was their age, or at a different stage of life, and explain to them what I had to learn to do, that it wasn’t something I loved to put on, emollients and creams on my skin, and I had to learn self-control about scratching and itching. I had to learn coping mechanisms for what to do for nocturnal pruritis, because that was a big part of what drove my disease. Then I talk to them about how life goes on, and as you get older, you may find that your disease hopefully gets better. I tell them that it doesn’t ever completely go away for most of us, but hopefully it will improve, and I explain what it’s like at this stage of life for me, and I think that’s helpful.
Melodie Young, NP: I think so too. Empathy is very strong and powerful. Let’s discuss the approach to AD care. There are many NPs [nurse practitioners] and PAs [physician assistants] who have full authority and ability to do whatever they want or need to do. Then there are others who work specifically with protocols or algorithms that perhaps the physician or medical director at the clinic has put together. Do any of you have a particular approach or algorithm? Do you have something that you always do first, or is everything on the table? Lakshi, tell me how you go about teaching since you teach other NP students. How do you teach them, say, “Here’s how we’re going to do the exam, we’re going to gather all this information from the family to understand the role, and then talk about therapy?” Where do you start?
Lakshi Aldredge, MSN, ANP-BC, DCNP: It’s great to mention that different practices may have different protocols. Regardless of what your practice setting is, it’s important for us as NPs and PAs to understand the management of atopic dermatitis. The American Academy of Dermatology has wonderful practice guidelines and algorithms to assist especially our more novice NPs and PAs, who may not necessarily know where to go. That’s a great resource. The National Eczema Association also has wonderful algorithms we can use. The mainstay of treatment with atopic dermatitis starts with moisturization. This is something that is important in adolescence or even in infancy to include the family and the young adult or teen with their moisturization preferences. Do they have cultural beliefs about the things that they apply on their skin? What are their bathing habits? Consider cultural preferences. Shared decision-making is important when it comes to their moisturization therapy.
With young children, it’s fun to make a game out of their moisturizing, this is their part of the process. We want to make it a game so that the child is applying the moisturization to their skin, and it makes them involved; that really helps with adherence. Moisturization and bathing at least once a day is important. We want them to moisturize ideally within 3 minutes of getting out of the bath or shower to seal in that moisturization. Overbathing can be more drying, especially if it’s not followed with immediate moisturization. The next step is to determine the severity of the disease. This can be done using numerous clinical tools, but from a practical perspective, how often are they flaring? How much of their body surface is affected and specifically which body areas? If it’s around the face, including the eyes and around the mouth, it may be more important to use a calcineurin inhibitor or a nonsteroidal preparation to preserve the integrity of the skin and decrease the incidence of atrophy or further skin thinning. This is especially important in the intertriginous areas. So calcineurin inhibitors, and topical steroids, our mainstay of therapy, especially for severe flares. Fortunately, we now have topical nonsteroidal agents that we can apply, which is reassuring for both patients and their family members to avoid skin thinning. We also have emerging topicals on the horizon that are nonsteroidal that will be a wonderful addition to our armamentarium.
Finally, for our more moderate to severe patients, even down to age 6 months, who are not controlled well with topical therapy, or even phototherapy, and are having a significant number of flares, it’s important to employ systemic treatment. We have more options besides the standard courses of systemic steroids, which were our mainstay of therapy, or even cyclosporine, which was used as a rescue drug for the more severe patients. We now have other agents that are biologic therapies that are specifically cytokine targeted, and have a wonderful safety profile and high efficacy. The algorithm includes moisturization, management of the skin barrier, identifying the incidence of skin infections, and the goal is to prevent flares and maintain skin integrity. Whether that’s topical, phototherapy, or systemic treatment, we’re in a good place where we have a lot of different treatment options.
Transcript Edited for Clarity