Dr. Siegfried: Do you use topical corticosteroid monotherapy for kids who present with mostly psoriasis or exclusively psoriasis?
Dr. Cordoro: Yes. Topical steroids are absolutely the leading treatment for psoriasis and atopic dermatitis. I start with a higher potency first. I don’t start low and build up. I try to get the child clear or near clear first and then titrate the potency depending on the extent, distribution and severity. Then I introduce more options, such as vitamin D analog on the weekends, or doing a vitamin D analog in the morning and the evening, or maybe introducing a topical calcineurin inhibitor.
Dr. Siegfried: How do you feel about patch testing children?
Dr. Cordoro: I think it’s fraught with problems, it’s hard to get enough surface area to clear to even patch test, and I think in the beginning, even if you are faced with allergic contact dermatitis, the goal no matter what is to treat and clear as best we can.
Check out part two of this three part series: Pediatric psoriasis, eczema:Triggers and therapies
I have been very lucky. UCSF has a really rich tradition of expertise in patch testing with Dr. Howard Maibach, M.D., and now our newest faculty member, Nina Botto, M.D., who came to us from Tufts University. I refer the kids for whom I am most suspicious and just cannot get them clear for any period of time or at all.
READ: The Irregular Border
Dr. Siegried: For kids who have psoriasis or eczema or inflammatory skin disease and who are using topical treatment only, how do you monitor medication adherence?
Dr. Cordoro: I don’t have the tricky tubes and jars that monitor how many times the lid has been taken off that Dr. Steven Feldman made famous in his studies on topical compliance. So for the lack of having trickery up my sleeve, I really just follow clinically. I think the most important thing is to assume that the prescribed therapeutic regimen is adequate to manage the different components of the disease. I assume that if I have given the right regimen and they are not responding, then there is either an overlapping factor that I missed and need to address or they’re not compliant.
I think the other clinical pearl that I have learned over time is that we really need to consistently review what is actually being used and how it’s being used to assure that what we have prescribed has been translated into the proper use of that agent. These regimens are not straightforward, and what the patient is actually using and how are they using it may not even closely resemble what we recommended. Medication adherence and compliance is really tricky because there are so many moving parts, and that’s part of the fun and challenge of it all.