Instructional handouts help caregivers stick to complicated treatment plans for pediatric AD patients. Historically effective AD treatments are being augmented with new phosphodiesterase inhibitors and biologics. Gentler approaches such as massage, light therapy, and melatonin may also be of value for children with AD.
Dr. SchachnerNo family whose child is being treated for atopic dermatitis (AD) should leave the office without an instructional handout, according to Lawrence Schachner, M.D., a professor of dermatology and former chair at the University of Miami School of Medicine.
“Many times, we are giving patients a topical steroid, a topical calcineurin inhibitor, an emollient, an antihistamine and an antibiotic. No one is able to keep that all straight without printed instructions,” Dr. Schachner tells Dermatology Times.
Dr. Schachner, who spoke at a symposium on pediatric atopic dermatitis at the annual meeting of Masters of Pediatric Dermatology in Miami Beach, Fla., said afterward that this is a disease that impacts the whole household.
“While the afflicted child is often itchy and unhappy, the family itself loses one to two hours of sleep on a nightly basis,” he says. “The family also misses many days of work and school time and will spend a small fortune on the topical care and the office visits.”
In fact, some studies report that a family’s quality of life “is equivalently altered to the quality of life for a child with juvenile diabetes,” Dr. Schachner notes.
Dr. Schachner’s office handout details daily care for the use of emollients, topical steroids and topical calcineurin inhibitors, including how to use them in the most severe areas, the milder areas, or when not to use them on a regular basis.
“Once the patient is stable and doing well, these agents can be used twice a week for maintenance,” Dr. Schachner says.
Several studies have shown that topical calcineurin inhibitors used for cleared atopic dermatitis, two or three times a week in areas of predilection of outbreaks, “will greatly attenuate the number of outbreaks,” Dr. Schachner says. “Some studies indicate that such intermittent treatment prevents outbreaks for many months at a time as opposed to placebo. Thus, not only do you have an active therapeutic effect with topical calcineurin inhibitors, but also a prophylactic effect.”
A similar prophylactic effect can be found by using emollients in newborns, in families that already have atopic children.
“This seems to decrease the number of patients who go on to become atopics as opposed to those who do not receive emollients,” Dr. Schachner says.
Besides discussing the various medications dispensed, Dr. Schachner’s office handout includes basic rules on short nails, short baths, hypoallergenic detergents (no bleach or fabric softeners) and keeping the patient’s environment cool.
For the child whose atopic dermatitis is stabilized, but then unexpectedly starts flaring, “the first three things you need to think about are Staph aureus, Staph aureus and Staph aureus,” Dr. Schachner states. “By addressing Staph aureus, 95% of the time the patient will become stable again.”
Herpes, tinea and contact dermatitis are three other destabilizers.
The handout mentions that for a history of Staph infections, an action as simple as a bath with quarter of a cup of bleach in a foot of water can help immensely.
Topical calcineurin inhibitors remain a very viable approach for safety and efficacy in moderate-to-mild atopic dermatitis.
“I believe these drugs were unfairly targeted by the black box warning back in 2005,” Dr. Schachner says.
One of the attractions of the calcineurin inhibitors initially, for Dr. Schachner, was that parents were “phobic” about their children being prescribed topical steroids.
“Parents thought steroids would turn their child into Arnold Schwarzenegger,” he recalls. “While this is not realistic, it was very much on their minds.”
Two new medication classes for atopic dermatitis are phosphodiesterase inhibitors and a monoclonal antibody like dupilumab (Regeneron/Sanofi). “Although phosphodiesterase inhibitors are not biologics as with dupilumab, they are approved down to age two,” Dr. Schachner says.
Among treatments for more severe atopics are light therapy, systemic steroids, cyclosporine, mycophenolate mofetil and intravenous immunoglobulin (IVIG).
“For light therapy, the consensus for chronic atopic dermatitis is that narrowband ultraviolet B is the safest and an effective therapy,” Dr. Schachner reports.
All these treatments can be used safely in the majority of children, “but they all have side effects for which you need to educate yourself,” Dr. Schachner says. “It is a risk/benefit ratio that you have to consider.”
In addition, studies of melatonin used at bedtime in children as young as one year demonstrate that sleep latency is reduced by 21 minutes versus placebo.
“In other words, a child who needs 44 minutes to get to sleep without melatonin, was asleep within 23 minutes with melatonin,” Dr. Schachner says. “Melatonin is a nice addition to other medications because it is really safe.”
Dr. Schachner observes this is an exciting time to be treating atopic dermatitis in children because there are new topicals (phosphodiesterase inhibitors) and systemics (targeted antibodies therapies).
And there are kinder and gentler approaches that can also be tried, including massage therapy.
“It is good to have some new guns in our armamentarium,” he says. “But do not abandon the topical calcineurin inhibitors because they still remain a good approach for safety and efficacy.”
Disclosures: Dr. Schachner conducts research and consults for Medimetrics and research for Astellas.