As cold weather is approaching for much of the country, it is crucial for dermatologists, pediatricians, and families to work together for proper pediatric atopic dermatitis care.
“I think we probably need education now more than ever because partially, people get their information in so many different ways,” said Larry Eichenfield, MD, regarding education surrounding pediatric atopic dermatitis (AD). In a recent interview, Eichenfield, the chief of pediatric and adolescent dermatology at Rady Children’s Hospital – San Diego, and a professor of dermatology and pediatrics and vice chair of the department of dermatology at the University of California San Diego School of Medicine, gave an in-depth review of treatment considerations for pediatric AD.
Eichenfield discusses how dermatologists and pediatricians can work together to ensure optimal pediatric care, the growing population of pediatric patients with AD, go-to treatment selections for pediatric AD, how treatment efforts have evolved over time, what’s new in the pipeline, and how misinformation on social media can be harmful to patient outcomes.
Larry Eichenfield, MD: Larry Eichenfield from the University of California San Diego and Rady Children's Hospital. Happy to be talking about what's happening in atopic dermatitis, especially in children.
Dermatology Times: How can dermatologists and pediatricians work together to ensure pediatric patients with AD are receiving the treatment they need?
Eichenfield: Well, it's a really good question given it's such a dynamic time in atopic dermatitis. There's so much information that we're processing relating to both our increased understanding of eczema, its impact on patients and families, and also, newer therapeutics that have really changed our management and will continue to, both with our topical medications and with systemic medicines. We have to work really carefully with our pediatric community of pediatricians and other health care practitioners who take care of children, just to keep them up to speed in these changes. I think that we have to be conscious of the messaging that we're giving to our patients and community, and then also our messaging to trainees in health care and our established pediatricians. So, I think we need a good positive approach. It's not hard to do that because we can bring so much more to the ballgame so to speak, in our management of eczema. We just finished a really cool project. It was a multi-year project where we did an initiative with our pediatricians in the community; it just got published in JAAD, it was called a multimodal initiative to improve pediatric provider management of atopic dermatitis. The whole purpose was to figure out what we can do to make pediatricians more comfortable in managing atopic dermatitis and then sort of being aware of the changing therapies.
Dermatology Times: Can you please discuss the growing population of children with AD and what you think is contributing to this increase?
Eichenfield: I'll start off with saying that we probably stabilized the number of kids with atopic dermatitis over the past decade probably. But if you look over several decades, there's a much higher rate. We have around a 10% to 12% rate of young children with atopic dermatitis, but some newer data and pretty strong data show that we have probably 7% of adults with atopic dermatitis of which probably half of them, it's leftover from childhood, but others are later onset. Our prior assessment was that atopic dermatitis was a young childhood disease and it got better over time. The epidemiology is a little bit different. The "why” is tricky; they're really competing theories, probably both of which may really be contributing to it. It could be that our immune system isn't busy taking care of parasites and things along that line of immune response, which makes it more vulnerable or easier to set up and hyper respond to other things because increased rates of eczema are also similar to increased rates of allergies, food allergies, asthma, that have similar immune aspects to them. Just as potentially important is our cleanliness, how we bathe, and our exposure to particulate matters in the air and pollution; all of that could be contributing as well making our skin a little more vulnerable and a little more hyper and then with pollution and particulate matter, that can be a stimulant potentially for overall in the population that might make eczema rates higher.
Dermatology Times: What are some of your go-to treatment selections for pediatric AD? Do these change in the winter months?
Eichenfield: It's so interesting because our traditional eczema season for most of the country are the winter months because in much of the country, it gets cold and there's heat put on in the living situation, like apartments and homes, and that further lowers the humidity. You can get this sort of exacerbation of dry skin tendency with eczema. We’re just finishing a season in San Diego, where we got hot. The heat was triggering a lot of atopic dermatitis. Sweat tolerance has decreased as well. The general approach is the same throughout the year but we're conscious of what factors might be triggers for individuals. Certainly, there are a lot of children who are born with a tendency to have dry skin. And if that skin is more dry, it has more tendency to break out into eczema, and also has more tendency to itch. And the more it breaks out with eczema and the more it itches, then the more scratching there is, which makes the skin more open, and you're in this cycle. So, the general standard go-to treatment is still first line, good bathing practices with moisturizing after bathing, and moisturizers to decrease the dryness of the skin. And it doesn't mean everyone has to be on the gooiest ointment, but if they have really dry skin, ointments are going to last longer than if you have a lotion that rubs on more easily, which may evaporate. Clearly, the biggest changes in our go-to's are that our go-to's are expanding for treatment of the inflammation of eczema that doesn't respond to moisturizer, which is a lot of inflammation in eczema. And traditionally, we use topical corticosteroids, but then we had to limit our frequency of use, or our persistent use of topical corticosteroids because of concerns about too much absorption or thinning of the skin. And while we know that there's definitely ways we can use topical corticosteroids safely, there's a lot of concerns about them. You can't use a topical steroid every day for a year.
When it comes to acute inflammation, we have a choice of either topical corticosteroids topically or non-steroid topically, and increasingly, a go-to is figuring out that you can get a patient under control with either the topical steroids or non-steroids and you usually can get patients under control, then we have to figure out what we need to do to keep it under control. We have now a different set of topical agents, including topical non-steroids, that can really be incredibly useful in regimens of care, either using medicines regularly in a proactive manner to stop eczema coming back, if someone otherwise would have frequently recurring or persistent eczema. Then in particular, it'll be really interesting over time with some of our newer agents that may cool down the eczema such that you can stop using the medicine for a while and have persistent effect, a sort of remittive effect without continued use of the drug to keep the skin under control. And that's especially intriguing as a possibility with tapinarof, which is an Aryl hydrocarbon receptor agonist, a new type of medicine that is being developed for atopic dermatitis.
Dermatology Times: How have you seen efforts of treating pediatric AD change over time related to clinical trials and FDA-approved therapies?
Eichenfield: I'll start with systemics quickly because I don't want to spend a lot of time on it, in this particular discussion. I want to highlight the more typical first-line and second-line of topical agents. But obviously, we've had new systemic agents. We always limited our use of systemic agents in pediatric patients to the most severe patients because the traditional immunosuppressives had such a worrisome side effect profile, and our newer systemic agents, biologics, and small molecules bring something different to the ballgame. But that’s still sort of a leap for a subset of patients who are more severe. But what we're seeing now, in our recent approvals and recent clinical studies, is a marked set of new medicines that are non-steroids and are going to be incredibly useful, either as a core therapy for patients or in regimens of care. Now, when those drugs are studied, they're generally studied on their own as compared to the vehicle so to speak, without the active ingredient in it, but we've seen a marked increase in clinical trials in non-steroid, so we already have approval of topical ruxolitinib, though from a pediatric standpoint, that's 12+, but they've done some studies in younger individuals as well. There is a limitation in the amount of use that that drug will have because with higher quantities of applications on the skin, you have to worry about absorption in the bloodstream. And then there are some other newer nonsteroidals that have just completed some of their trials, including tapinarof, which had a study on it already approved for psoriasis in adults. But tapinarof with the same formulation, Vtama is the trade name, 1% tapinarof cream was studied for atopic dermatitis in 2 big phase 3 trials down to age 2 and showed very nice results. And so that'll be very intriguing. Roflumilast is a PDE4; they're using different concentrations to study at different age groups, another non-steroid. I think that having non-steroids could be incredibly important to try to get these regimens of care where someone can have periods where they're free of rash, free of itch, minimal concerns about using the topical products, if they're tolerated well with good side effect profiles and not concerns about toxicity. And I snuck in before this potential for a remittive effect where you can treat atopic dermatitis and then seem to clear it and have it not come back for a period of time without mediation, a so-called remittive, which has been seen with tapinarof in psoriasis, and we'll see how that shows up in our clinical trials with atopic dermatitis which is really very exciting.
Dermatology Times: What is currently in the pipeline for pediatric AD that you are looking forward to?
Eichenfield: For the 3 topicals that are sort of well along the way, ruxolitinib, Incyte’s drug as I said, it's approved for 12+, but they have some pediatric data, which will be presented forthcoming, they already had some pharmacokinetic data in that age group. We'll see if that gets approval as a pretty potent non-steroidal. Roflumilast is approved for psoriasis at 0.3%, they did studies for patients ages 6 years and older with 0.15% cream, and a younger set of studies did that with a .05% cream, that's a PDE4 inhibitor. Tapinarof is as is an Aryl hydrocarbon receptor agonist and that 1% cream is the standard formulation that's been approved for psoriasis. And they finished up their 2, phase 3 ADORING studies earlier in the year, and we're going to be seeing new data come out as well. It'll be exciting if we get those drugs approved by the FDA and into our hands so we can help our patients.
Dermatology Times: October is National Eczema Awareness Month. How do pediatric patients with AD factor into educational considerations for parents and caregivers?
Eichenfield: Thank you for asking that because I think we probably need education now more than ever, because partially, people get their information in so many different ways. Some of the ways they get their information, it's not even not filtered, it's just wrong. I have people come in and they're quoting their TikTok videos, and maybe that's a good TikTok video, but there's some bad ones. And there's a sense of concern, probably much concern, about some of our traditional medicines. I do think that we want to very much support people's learning about the disease so that they're part of active decision-making on the medicines that they use, and it's going to be easier with our newer set of medicines to get them to understand the relative safety of them and how they can be used to really change the impact of the disease. I think we can bring most of our patients to minimal rash and minimal sleep disturbance, which makes the whole family happier, as well as decreasing the eczema and the secondary consequences.
Dermatology Times: Do you find that there is considerable misinformation about pediatric AD on social media?
Eichenfield: Yes, we occasionally get these patients who recently over the past year, the kids get admitted with serious infections from eczema, requiring IV antibiotics. We worry about the infection in the bloodstream, and the family work themselves into not using any medicine because they were so concerned from the information that they got, that they weren't even going to use topical steroids or didn't want to use anything. We have to work to really get them to understand that inflammation is tied with infection and the reason why the child is admitted with infection is because there's so much inflammation in the skin. The good news is we have lots of different options in terms of managing that, but misinformation in this case fueled their approach to the disease that it was harmful. We just have to work with them to get on the same page and to just educate them about what the process of the disease is, and how we can fix it.
[Transcript edited for clarity]