In part three of our discussion about pediatric dermatology, Kelly Cordoro, M.D., associate professor of dermatology and pediatrics at the University of California in San Francisco, discusses screening labs, avoiding complacency, and the ABCDEs of melanoma with Dermatology Times editorial advisor, Elaine Siegfried, M.D.
Dr. Siegfried: You wrote a great paper about screening labs and the relative value of screening labs when using systemic agents for kids with psoriasis. Given whatever your favorite drug is, which labs do you routinely check and how often?
Dr. Cordoro: Thank you. I really wanted to research more about these drugs and what are the differences. We get most of our information on screening from other subspecialties: We borrow from the rheumatology literature; we borrow from the hematology-oncology literature; we borrow from the gastrointestinal literature. We don’t have our own data-driven evidence for kids with psoriasis specifically, or for kids with atopic dermatitis specifically to really answer these questions. So my approach is very clinically driven.
Check out part 1 of this three part series: Clinical pearls in pediatric dermatology
I start out very conservatively. I will check labs at baseline and fairly frequently early in the course of therapy. And the specific labs and frequency differ depending upon the specific agent used.
We know for cyclosporine, we have to be more aware of checking blood pressures, electrolyte levels and kidney function. With methotrexate, we have to be more aware about testing liver function and so forth.
Over the course of therapy and depending on the patient’s individual situation, their response to disease and lab results, I’ll check more or less frequently. Even though we have published recommendations, your clinical experience and the individual patient will prompt a variable approach. I will liberalize or tighten the lab monitoring as the clinical course evolves.
In developing the AAD’s clinical guidelines for management and treatment of atopic dermatitis with phototherapy and systemic agents, we agreed on recommendations for monitoring. Those were derived based on available evidence and expert consensus.[i] There are charts in the manuscript detailing the dosing and recommendations, and I follow those pretty closely.
For psoriasis, my approach is similar. It’s really a more aggressive approach upfront and then adjustments over time based on individual factors. My recommendations around that can be found in an article that Anne Marqueling, M.D., our former pediatric dermatology fellow who is now faculty at Stanford, and I wrote called “Systemic Treatments for Severe Pediatric Psoriasis: A Practical Approach.” This contains straightforward and clinically driven suggestions for baseline and then ongoing monitoring.[ii]