Optimizing Treatment of Pediatric Atopic Dermatitis - Episode 10
Lawrence Eichenfield, MD: We have had new topical medicines that have joined topical steroids and topical calcineurin inhibitors [TCIs]. I want to talk about the efficacy and safety profile of the TCIs in pediatrics, as compared to PDE4s [phosphodiesterase type 4 inhibitors], and how to use these as compared to topical corticosteroids in practice.
Fred Ghali, MD: About 20 years ago the TCIs came to market, both pimecrolimus and tacrolimus. Pimecrolimus was approved for children 2 and older for mild to moderate AD [atopic dermatitis], and tacrolimus for moderate to severe AD in 2 and older for patients who are not responding adequately to traditional therapies, moisturization, and topical steroids. I think the niche for these drugs was mainly on sensitive skin areas, like periocular areas, groin areas, intertriginous areas, and some people used them in combination with topical steroids for maintenance for long term or intermittent therapy.
In 2006, I think it's worth mentioning there was a concern about potential malignancy risks on this class of medications, and there was a black box warning that this class of medications received. Several advocacy groups and patient groups made comments that they didn’t feel like this was appropriate for a black box. Since that time there have been registries done on both pimecrolimus and tacrolimus showing their safety over the long term.
I think they definitely play a role and have a place in the management of atopic dermatitis. For myself, I tend to use them on sensitive skin and thin areas where I’m reluctant to use a topical steroid.
Lawrence Eichenfield, MD: And PDE4 now, they’ve expanded indication down to 3 months of age. It's the first time we've had a nonsteroidal for less than 2 years old.
Fred Ghali, MD:Right. The PDE4s as of spring this year got a label indication, an extension down to 3 months of age. I think I'm still getting a feel for the topical PDE4s. I know some of the clinical data haven't always matched up to the real-world data. There have been concerns about tolerability and efficacy, and so I think we're still trying to work it out.
Lawrence Eichenfield, MD: Crisaborole’s safety does look incredibly good.
Fred Ghali, MD:It looks very good.
Lawrence Eichenfield, MD: There's really no limit to duration of use, which is nice to have when you're looking for nonsteroidal regimens.
I wanted Peter to finish up in the outside of the box to a degree, alternative and complementary medications. I think patients will look, families will look for that, even in pediatrics. What's your sense of that, Peter?
Peter Lio, MD: It's true, they really do. When you look at these studies, it's over 50% of patients and families have at least explored some of the alternative and complementary medicine options. And I think that speaks a lot about where this has been. I'm hopeful that that will go down as we have new and better medicines that have a much more favorable safety/efficacy balance, but that's where we've been. I will say atopic dermatitis is what drove me into learning more about alternative medicines, because I felt so frustrated that we didn't have all the right tools.
People try everything, and this is a very encompassing approach. This can mean everything from simple stuff that's kind of blurred at the lines of the evidence, like vitamin D supplementation, probiotic supplementation, and then it gets farther and farther out. Different types of botanicals. What do you think of coconut oil? What do you think of sunflower oil? And then we get further, hemp supplementation. Then you get really far out, Chinese herbs, acupuncture, acupressure, Reiki, energy medicine systems, you go farther and farther. And it's interesting because there really is a track of evidence too. Some things are really far out, and frankly some things have been shown simply not to work. Homeopathy is an interesting system, it has its own tradition, but when you look, the majority of studies that were really looking at atopic dermatitis showed that it just doesn't help.
I feel pretty comfortable saying, “Gosh, I hear that you're interested in the system, but I don't think we're going to put our attention here.” But then you have other things like certain botanicals that you say, “Well, wow, this has not only data in a laboratory that shows it may have good effects, but look, these small clinical trials do show some effect.” We try to weigh all these things, and of course almost none of these are going to be the only answer, but they can often be adjunctive therapy for certain patients. And sometimes just being open to that I think can help establish that rapport and get that buy-in so that the patient says, “OK, we're a therapeutic alliance instead of you're fighting me at everything I want to do.”
Lawrence Eichenfield, MD: I think that's a big takeaway, don't be afraid to ask about what else is out there or they're using, and I think comprehensive care would want you to weigh that into your decision tree on how you move forward.
Transcript Edited for Clarity