Expert Perspectives in the Management of Pediatric Atopic Dermatitis - Episode 5
Experts in dermatology review the treatment landscape for pediatric patients with atopic dermatitis.
Raj Chovatiya, MD, PhD: You both alluded to the changing treatment landscape, and now is as good of a time as any to talk about some of the treatment considerations for our pediatric patients with atopic dermatitis. This is something we all love to chat about when we’re hanging out. To transition to that point about caregivers, I think we largely highlighted that there is a huge role caregivers have in terms of preference in treatment selection, and as Britt so eloquently put it, depending on the stage in life, in many ways it’s going to be a caregiver driving the plan. At some point, you start transitioning to people having their own personal freedom to make a choice. You really have to feel out what the unique situation is in the context of the clinical encounter. The first question, and I’ll toss this one to you, Peter, is when is treatment commonly initiated in pediatric patients with atopic dermatitis? What are the triggers, in your practice or in general, to initiate therapy? When is it that we say we have to do something here.
Peter A. Lio, MD: I really like the concept of the therapeutic ladder. So for the mildest patients, and frankly, for everybody, we always want to start with the lowest rung, which is going to be good skincare in general. So, good moisturization, gentle cleansing, and avoiding known triggers. All of that piece goes with the education. For some patients, we don’t get to see them, but out in the world, that may be all that they need. That’s great. I’d prefer not to medicalize stuff that doesn’t need to be medicalized. We’re busy enough. I always tell my patients, you’ll never see my face on a billboard, I never advertise, I have all the business I need. I don’t want any more patients. I’d rather have patients be better and not need us. That’s part 1. Everyone starts there.
If they’re still having symptoms, in particular itch, but sometimes we know pain as well can be associated with this, then I think we have to do something, at least reactive treatment. That’s sort of the next level up on the rung. Historically, we’ll use topical corticosteroids because they fit the criteria for an excellent first line. They’re very accessible, generally cheap, most patients can get them. They’re highly reliable. Almost every single patient who uses them is going to have a good response to them. There are some who don’t, obviously, but much better than the alternatives. Then finally, the fact is that they can be used very safely when we use them properly. So in a reactive setting, we do it for a little bit, then take a break. That’s going to get another huge chunk of patients with atopic dermatitis in the mild range.
But what if that’s not enough? OK, next rung. Then we start thinking about some of the proactive therapies, or maintenance therapies, and one of my favorite papers was from Professor Andreas Wollenberg in Munich, Germany, where he talked about this idea of proactive treatment with tacrolimus on the weekends. He was able to show that by having patients put tacrolimus, one of our calcineurin inhibitors and a nonsteroidal agent, on the trouble spots on the weekends, he was able to improve quality of life, decrease number of flare-ups, and decrease overall medication exposure over time. This is very much cribbed from the notes of how we treat patients with asthma. Obviously, if someone keeps having bad flare-ups, we don’t just keep treating them. Eventually, we see we need a maintenance therapy. That’s where I really think our nonsteroidal agents can shine, and now we’re lucky that we have a few different ones. We have tacrolimus, pimecrolimus, we got crisaborole in 2016, and then just last year we got topical ruxolitinib. So we finally have some really neat nonsteroidal medications that we can integrate in this role. Personally, I still like to use topical steroids as my first line unless there’s some reason not to.
Then, what if that’s not enough? Well then we get into the bigger guns. We start talking about systemic therapies, and now we have a lot of options. We have our biologic agents, we have our JAK inhibitors, and of course we have phototherapy, which is one of my favorite things to do when it’s feasible. Then, of course, we have our traditional immunosuppressive drugs that we’ve used for a long time, as Dr Craiglow mentioned earlier.
Raj Chovatiya, MD, PhD: Very nice overview. I think we’re going to break it down one-by-one and talk a bit about some of those categories that you mentioned before I talk about some of those nonpharmacological approaches, which I think we don’t honestly hear and talk about nearly enough because those folks may not even be getting to us in practice.
Transcript Edited for Clarity