Risks of Under-Treating Severe Atopic Dermatitis in Children

Eingun James Song, MD, dermatologist, director of clinical research, and co-chief medical officer at Frontier Dermatology, recently discussed how he counsels families on treatment for severe pediatric atopic dermatitis (AD) in a Dermatology Times Expert Perspectives custom video series. He also addressed emerging post hoc data on dupilumab (Dupixent: Sanofi and Regeneron) and growth in children. His commentary covered the risk of under-treating disease, how he explains biologic therapy, and the research still needed.

Weighing the Risk of Under-Treating Severe Disease

Song said safety discussions with parents apply to any treatment, not only biologics. “We could talk about the risks or some of the safety concerns of any particular medication, whether it’s a cream, a pill, or a shot, but we also need to focus on the risk of under-treating a disease,” Song said.

He cited compelling evidence of higher risk for type 2 comorbidities, including asthma, food allergies, and nasal polyps, among children with severe atopic dermatitis when disease is not well controlled. Neuropsychiatric comorbidities such as anxiety, ADHD, and depression also carry higher risk.

Bone growth now enters the discussion. Song said these patients may be smaller and might have grown taller had intervention come at the right time. “I always try to balance what’s the risk of over-treating versus the risk of under-treating,” Song said.

Framing Biologic Therapy for Families

Song said a biologic is not inherently safer or more dangerous than other treatments. “A biologic does not necessarily make a treatment inherently more safe or more dangerous. It’s just simply a byproduct of how it was produced,” Song said.

He compared biologics with insulin and vaccines, both derived from living organisms. In atopic dermatitis, he often likens a biologic to an allergy shot, while acknowledging the comparison is not entirely accurate. “I have found the best success of actually likening it to an allergy shot,” Song said.

Limitations of Post Hoc Growth Data

Song noted the growth findings come from post hoc analyses, not studies prospectively designed and powered to show height differences between children receiving dupilumab and those receiving placebo. A dedicated trial may face logistical and ethical challenges, since delaying an effective medication raises concerns.

Even so, he said objective biomarkers beyond bone alkaline phosphatase, imaging such as DEXA, and height and weight measurements could add information. Researchers would need to control for topical corticosteroid use, sleep, and diet. “I think trying to capture as much data when it comes to growth is going to be important for us,” Song said.

Drug Effect, Class Effect, or Disease Control

Song said providers first need to know whether the benefit of dupilumab is real. “Is this more of a drug effect? Is it a class effect?” Song said.

He noted IL-13 inhibitors, IL-31 blockers, and JAK inhibitors may show similar growth benefits as approvals extend to younger children. Song expects clinical trials to capture more data, which will clarify whether the goal is a particular therapy or simply disease control. He called this the most important question.