Angela J Lamb, MD

Another thing to talk about with topical corticosteroids is that I have a lot of patients come in with hypopigmentation and areas of atopic dermatitis. They have been told that that is from their hydrocortisone or maybe triamcinolone. We need to dispel the myth about topical corticosteroids causing dyspigmentation because that’s very unusual. In these patients, it’s almost always a post-inflammatory change. Do you see the same thing?

Yes, it’s usually post-inflammatory. You’re right. Sometimes people don’t know what they’re looking at, and it’s the same way with post-inflammatory hyperpigmentation. They’ll say, “My eczema is still there.” I’m like, “The eczema is fine. Are you itchy? I don’t feel any plaques. Your skin is very flat. This is the scar that’s left over after the atopic dermatitis is gone.”

Post-inflammatory hyperpigmentation can take a long time to resolve. That’s another thing we have to think about when treating patients. Every time they get a patch of eczema, they’re getting a darker patch left behind for months or longer. That’s a big deal for them. Thinking about that as another component of treatment is useful.

That’s almost as important because sometimes people are traumatized by that. They’ll say, “I had a period in my late teens when my eczema was on fire. Now I’m in my 20s or 30s, and I still have patches.” That can be devastating, especially for patients who have more melanin in their skin.

Yes, for sure. We saw this a little more before dupilumab, but some kids are very itchy, scratching so much that they have dyspigmentation sometimes. We can’t get back from that. That’s a sequel that shouldn’t happen. In closing, there’s a lot of reason to be hopeful in atopic dermatitis. This isn’t a thing that kids should have to live with. Maybe they’ll get better over time, but this is having an impact on them and their family, so we need to treat it.

Any closing thoughts about the role of the pediatrician and our job as dermatologists and working together to get the best for our patients?

 Stay in close contact. I’m not like you. I’m not double-board certified. But I’ve had the good fortune to train at a program with a robust pediatric dermatology program. I trained under some great pediatric dermatologists. I’ve always felt comfortable managing some intense dermatology stuff. I know I’m outside my genome dermatosis when I’m outside my wheelhouse. I have a lot of experience in this space. The pediatric practice downstairs refers patients exclusively to me. Having that close relationship and accessibility is critical. Children are coming through their parents. If your child is suffering or in pain, you want a response right now. Having that close contact. Also, educate them and let them know there are exciting things in the pipeline. I’m excited about the JAK inhibitors, hoping we get good approvals for those in this pediatric population. It’s really exciting.

For sure. We have baricitinib approved down to age 12 now. That’s for patients who fail dupilumab, because there are some. We have even another option, and this is the beginning. It’s exciting for us to have more tools, but also for patients. Sometimes the conversations take a bit longer. There’s more education, but if you can help 1 of these children and their families, there’s no better feeling. Talk about burnout and all these things that we have to deal with in medicine. Ultimately, we all do this to help people. When you have that feeling that you helped somebody, you changed their life—the child is sleeping through the night or going to school—that feels good. That helps sustain us. Remember that when you’re taking a bit more time, it will pay off in the end.

It’s been fun to talk with you. Thank you for watching this 

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Videos

Brittany Craiglow, MD, and Angela J Lamb, MD, share closing thoughts on the role of pediatricians and emerging treatments in the pipeline for pediatric AD.

Role of Pediatricians in Management of Pediatric AD

Let’s talk about dupilumab. This has been a major breakthrough in dermatology. We’re going to look back and identify it as 1 of the biggest things that’s happened in 20 years for our patients. It’s approved for ages 6 months and up, which is exciting. Tell me about your experience with it. When do you start thinking about it? Is this a patient who might warrant dupilumab?

 Yes. Based on the lifestyle and the body surface area involvement, I’d seriously consider it. From an integrity standpoint, it’s always important to try some topicals and adjust the skin-barrier protection first. If somebody is coming to me—unless they’re completely covered and miserable—there’s no way they’re ever going to be able to apply topicals or even barely apply moisturizers because of the amount of involvement. If it’s my first visit, even if I think that might be in their future, I’ll see how clear we can get them and what we can do for them. I want them to buy into the fact that even with dupilumab, you’re still going to have to use your moisturizers twice a day. You still have to wet your skin every day. That that’s a big piece of this. These medicines are game changers. I love them. But because atopic dermatitis tends to be so chronic, I don’t want people thinking that they’re going to have a medicine—a pill, an injection—and then they’re clear and can do whatever they want to their skin.

Barrier protection is key. It’s important. There are some breakthrough areas. There’s going to be that resistant patch. You’re going to make it so that that resistant patch is gone by applying your moisturizer twice a day. As annoying as it is, I want them to accept that this is a chronic disease, and we’re going to have to manage it. Some of that is going to involve not just an injection every 2 weeks or every month. It’s going to be about how you take care of your skin.

 Yes, because you can’t escape your genetics in that barrier. It still needs support. It’s not the time to use fancy cream at your favorite store. That’s hard, especially for teenagers. They want to do things that their friends are doing. Acknowledging that, I get that you want to use X, Y, and Z, but this may put us back to where we were previously. Maybe we can talk about injections and kids, because dupilumab is an injection. Nobody likes shots, but kids really don’t like shots. How do we navigate that with our patients? What are some things we can do to make that easier for them?

 We always tell patients to leave the injection out 45 minutes to an hour because it’s more viscous. Also, I recommend an ice pack before, but be careful not to leave it on too long. A little ice pack will soothe the area and get it ready for the injection. Those are some of the main ways I help people manage that. I find that my adult patients have more needle phobia. Kids tend to be OK. They get along. They jump on board. The adults are like, “Wait, hold on.” They have some real anxiety, some real needle phobias. Some can’t tolerate it, unfortunately. I’ve never had that with kids.

 Yes, it’s infrequent that it’s a deal breaker. That bit of discomfort for a short time vs all the time that you’ve been spending taking care of your skin—that goes a long way. For young children, the injection is monthly. So 12 shots a year is not a ton. Going back to what you were talking about, you’d try topicals in this patient first. It’s important to note that sometimes we see a patient who looks like they’re headed for systemic therapy, but it’s because they’ve never been treated appropriately. Sometimes I’ll say, “We’re going to use this medicine called triamcinolone.” And they say, “I’ve had that before.” First, how big was the tube you had? Maybe they had a 15-g tube when they have 20% body surface area. And how did you use it? For a few days here and there?

An important thing to understand, especially for pediatricians, is the way we use topical corticosteroids and atopic dermatitis. It’s OK, and you’re not going to cause a problem doing this, but you need to use enough and use them for long enough. Give the patient a 1-pound jar of hydrocortisone 2.5% or triamcinolone, and have them do it twice daily for 2 weeks straight, even if they’re better. I tell patients think about it like a fire that you want to put out. Pediatricians should feel empowered. Even among health care providers, there’s this topical steroid thing. It’s not just among parents. But when you use it appropriately, it’s safe and can be a great option for patients. Once you put that fire out, people do better.

 They’re good with their barrier protection after that. I’m sure you know the literature, especially before some of these newer medicines came out. Good barrier protection works. I had a patient who was a child of a physician, and I wanted them to get the skin wet every day and use petroleum jelly with occasional topicals. She was like, “He’s cured.” I took the time to explain how you take care of your barrier using a cool-humidifying room when you have atopic dermatitis. There’s been a lot of literature about that. Sometimes we have to convince people that it’s that easy. A caveat is that for many patients, that doesn’t work. We’re talking about dupilumab. We’re talking about how I don’t want to give the impression it’s that easy. For some, it is. It’s hard to know until you take the time and write it down and do solid patient education. Then they buy in. They see that they can do this, and maybe I don’t need that medication.

 A lot of dermatologists use an eczema action plan, like an asthma action plan. That’s something that pediatricians could certainly do. Maybe for those who don’t have as good access to dermatology or are interested in treating more themselves. It’s an easy thing. This is what you do when you’re flaring. This is all the gentle skin care stuff. The simpler we can make it, the better. Try not to do multiple topicals if you can get away with 1—maybe 2 if you need a little higher potency for the body and lower for the face. Patients like to have that plan, and it seems more manageable when it’s kept simple.

Expert dermatologists review the use of dupilumab for treatment of pediatric AD, and how topical and injectable medication can impact a patient’s lifestyle. 

Use of Dupilumab in Pediatric AD

 Given the percentage involvement, do you think this patient warrants dermatology referral right away? Or do you feel she hasn’t tried that’s not over the counter, so the pediatrician tries triamcinolone twice a day for a couple of weeks to see what happens?

 She tried nothing but over-the-counter medication, so I’d probably go for a medium-potency topical steroid and then quick referral to a dermatologist. That’s mostly because of lifestyle. Sometimes the disease burden or body surface area is not directly correlated with how much is impacting somebody’s life. I’ll even take out that they talked about sleep. Sometimes kids are getting bullied, teased as if something is on the face—people start saying things. If there’s no clearance with that move quickly because of the lifestyle, then that needs to drive some of these decisions.

 That goes back to the treating the patient, right? For our initial discussion, as you mentioned, we talk with these families about what’s happening in eczema and gentle skin care. A lot of the families are doing everything right. They’re using a bland emollient. They’re not using soap or they’re using a soap-free cleanser. Sometimes I have families say, “I don’t understand. We’re doing Aquaphor every day, but she’s still itchy.” Talking about the barrier defect and all those things are important for barrier, but when you have inflammation, you could put moisturizer on until the cows come home and you’re still going to have itch. We have to treat the inflammation. Usually, the way we do that is topical corticosteroids, at least initially, but sometimes we get pushback with that. There’s this phobia about these medicines. How do you address that with your patients and their families?

 The use 2 phrases that stops it in its tracks. One, I tell people I would use these in my children. I have used them in my children. And 2, I tell them that it’s stressful to the body and raises internal cortisol for somebody to be itchy and stressed about their skin. The amount of cortisol involvement from the topical corticosteroids is so minimal compared with the stress of having itch and not being able to sleep. I like them to think about it like that. I find that tends to be a game changer. [Then I can] treat this child and put them out of their misery because it’s stressful. Itching is incredibly stressful to the family because it can create this power dynamic. The parent is telling the child to stop. I want to redirect them to focus on corticosteroids, which used under correct physician supervision do beautifully. People don’t have a lot of adverse effects. Research has been done on the amount of internal absorption—it’s fine, and there’s nothing with adrenals. But it’s very stressful. Your body’s internal cortisol is increasing when it’s stressed and you’re itchy and not able to sleep.

 It’s easy for a parent to view it as just a skin thing. But we have to remember the impact on the quality of life and other things, especially for young children. What does it mean for their sleep to be disturbed at a young age? There’s a lot of brain development happening. There’s still plasticity there. I sometimes say, “A lot of the calories your child is taking in are going to her skin. We want them to go into the brain, the kidneys, and other places where it’s more important.” We have to show that it isn’t just the skin. There are reasons beyond making them look less red or less itchy; that can be helpful. We also have to tell them that it’s not a forever thing. There’s an appropriate way to use these medications. If they become something that need to be used regularly, we’ve got to move on. We need to move up the ladder to a nonsteroidal, a topical steroid, or dupilumab.

Angela Lamb, MD, shares her approach to treatment selection for pediatric patients with AD.

Treatment Selection in Pediatric AD

 Let’s move on to our case discussion. We have a 7-year-old girl who presents to her pediatrician with worsening of patches on her face and elbows. Prior to this visit, she had noticed these patches out of the blue about 6 months earlier. She had been managing her atopic dermatitis at home since then. The family had asked the local pharmacist what they recommended, and that person had suggested a combination of emollients and moisturizers. They’re using over-the-counter hydrocortisone 1%.

This has helped a little, but the patient continues to flare, and she’s getting flare-ups pretty regularly and having some trouble. She’s waking up at night because she’s itchy, and that makes it hard the next day to get up for school. If she makes it to school, she’s having trouble concentrating on her exams and things like this. In class, she feels embarrassed. It’s affecting her behavior too: she doesn’t want to raise her hand because she’s worried that her classmates are going to see the rough, dry spots on her arms and ask her about it, or be worried that maybe she’s contagious or something. She’s skipped school for the past couple of days because her face is very red and irritated. It’s having a big effect on her life.

We look at her chart, and the last exam she has documented shows that her skin was normal. When you look at her today, she has patches on her face and elbows and has about 12% of her body surface area involved. Otherwise, she’s totally healthy. She doesn’t have allergies, she doesn’t take medicines, and has never had a rash like this in the past. What are your initial thoughts about this patient?

My first thought is that with atopic dermatitis, 1 of the things we have to help families realize is that it can come on suddenly. Everybody thinks they had to have had it as an infant or even had any family history, but it can present like this, you’re fine, 1 year, the next year, not. For my next step, for anybody this abrupt, I might consider getting them patch tested to make sure, to cover my bases in that regard, to make sure there’s no allergic contact dermatitis going on that might be contributing to the atopic dermatitis. That might not be the diagnosis, but it sounds consistent with atopic dermatitis.

I agree. Oftentimes, we’ll have a perfect story for it, right? The patient was started around a few months of age. His cheeks were always red, and he also has food allergies, asthma, and the whole shebang. Sometimes there are who show up and we’re like, “What happened?” In those cases, especially for the families, is it the diet? Is it wanting to blame it on something? It’s harder to understand that this is a genetic predisposition. She’s 7 years old, and nothing has happened until now. That conversation sometimes needs to happen at all ages. But when it comes out of the blue, it makes families think there’s something causing it. As you said, with allergic contact dermatitis, maybe there is. Some of these kids who have atopic dermatitis also have concomitant allergic contact dermatitis. It’s something to think about. But oftentimes, it is what it is.

When you look at her, how do you envision her management? Seven is an age when kids sometimes start to be involved in their care, but is this something the parent needs to help out a lot with? What’s going to happen at home?

Usually, with children this young, the parents are involved. My cutoff for lecturing the kids on how to take care of their skin—I shouldn’t say my cutoff, but my initial conversation—is around 10 or 11 years old. I talk to them about how this is the skin you’re in. I try to have them transition to thinking about atopic dermatitis as something that we’re not going to be able to cure. You’re going to have to manage it, almost like diabetes. If you had diabetes, would you not take your insulin? I have those types of conversations. But under age 10 or 11, I find that you’re not going to have a lot of success. Kids don’t have a strong enough consciousness to understand those more sophisticated concepts.

For 7-year-olds, parents need to be all in doing all the things we talked about: the emollient care, the bathing, or daily getting the skin wet and then applying the medications as indicated. Here, they were saying 12% body surface area. This is a large lifestyle burden for this family. There are no pictures here, but because she hasn’t been on anything, I’d probably start a topical, medium-potency topical steroid and then quickly taper to a steroid-sparing agent. If there were a lot of rebounds and still a lot of interference with the lifestyle, then I’d quickly move to 1 of the newer medications we were talking about, like dupilumab, which has been a game changer. It’s FDA approved for a 7-year-old, which is exciting. I’ve had good success using it in this age group as well.

Brittany Craiglow, MD, and Angela J Lamb, MD, share initial case impressions of a 7-year-old female patient with AD and discuss the key role of parents in disease management.

Patient Case: 7-Year-Old Female with AD

It’s great. We have some work to do. Especially for patients who have Medicaid or in underserved areas, access can be difficult. Is there any way specifically you address that?

What we have tried to do, as you said, there are some better models of it in things like psoriasis. I know we’re talking about atopic dermatitis now, but for example you have that model where you have the e-consults or you do a multidisciplinary e-visit, where multiple physicians are going back and forth and we can give recommendations, and then also do technology-based checkpoints with patients. Doing outbound communication, asking them how they’re doing. In something like a chronic condition like atopic dermatitis, what happens is people contact me when they’re in a crisis. A season change, things like that, they’re in a crisis, they need an appointment tomorrow. Well, you’ve had atopic dermatitis for a while. Even children struggle, so we can perhaps do better outreach, which there are some good models for, depending on what technology system you have at your practice or your system, where you get ahead of it, everybody with this diagnosis gets an outbound message stating, “Do you have your refills? Are you ready?” That avoids some of that burden on physicians where we don’t feel like we have agency, we’re getting dumped on, people are coming to us right before an event, this is a holiday week, everybody wants everything before they leave for vacation. If we had been able to get ahead of that knowing that with atopic dermatitis, this is the time of year you’re flaring. There are some good models of that, I think, that improve access and minimizes physician burden, as well.

I love that idea. You catch them before they fall. And it’s propping us up, too, because you’re preventing a lot of those things that happen when patients do fall—they lead to more time on the EMR [electronic medical records] trying to fit people in, busier clinics, etc. Maybe over time, one could imagine that those check-ins help the patients stay on top of their care better because it becomes more part of their routine. That is one thing about atopic dermatitis I remember when I was a resident thinking, gosh, why can’t people do what I’m asking them to do? And then I had my own kids, and I was like, wow. So I think, again, we have to work with the family to figure out, is this something that you can do? Is this reasonable? If you’re asking somebody to do something twice a day and the parents are up and out to work before the child wakes up, does the kid hate grease? Well, if so, then we probably shouldn’t be giving them an ointment. So meeting the family where they’re at is important, [as is] having them participate in the plan, because you can’t make some wild and crazy regimen and expect someone to do it if you couldn’t even do it yourself.

 The treatments are not always difficult. We’ll get to that in a bit. That’s what is so powerful about some of these newer medications that have come into the fold and, hopefully, we’ll have more indications for them for the pediatric community because slathering creams is not it anymore. Separate topic, but now we have things that are much more aligned with people’s lifestyles and how they live their lives.

We accepted that because our options weren’t great before. I used medicines like cyclosporine and methotrexate when I had to. But having an option like dupilumab has made me realize I was undertreating a lot of people, even when I thought I was being aggressive. A lot of those patients in the middle who you felt like their AD isn’t bad enough to justify the blood draws and the talking about box warnings and all this stuff. You settle for this less-than-optimal option. One thing we need to do as a community and help pediatricians understand also is that it doesn’t have to be the way it used to be. Times are changing. This is a disease where now we can get most people to clear or almost clear, and largely in a safe way. That is something that takes a while. You get stuck in your ways, but a lot of the things that we used to ask people to do aren’t feasible for most families. There’s data that the average caregiver of a child with moderate to severe atopic dermatitis spends like 20 hours a week caring for their child. One of the things I say to parents is that when the child has it, you have it. They’re waking up at night. They’ve got grease on their clothes.

That’s the whole thing. I have 3 children. My youngest one is 9 months. I can barely give him a bath.

We’ve talked a lot about communication with pediatricians. Obviously, that’s important. In systems where everybody has a shared medical record, that’s useful. But when there aren’t, do you send letters, or how do you communicate with your referring doctors?

Mostly sending letters. It’s the old-fashioned way, sending letters, emails, texting, that’s it. Again, the EMR has been a game changer. I don’t do that as often anymore because we can communicate through the health care record.

Drs Brittany Craiglow and Angela Lamb provide insight on how they address access to care issues that arise for patients with pediatric AD.

Overcoming Barriers in Accessing Care for Pediatric AD

There are a lot more tools in our toolbox now. Part of this is us educating the pediatricians, saying, hey, we have more things now. Yes, we do topical corticosteroids, but we have these other options. We have dupilumab now for kids who are severe or moderate to severe. There is this mentality sometimes that the kid’s going to grow out of it. And, sometimes, maybe the referral doesn’t happen. I think, wow, how did it take you so long to get here? And I’ve heard from kids that they said he’d grow out of it. Maybe he will, but in the meantime, he’s suffering. Treating it is important. Especially with what we know about the atopic march. It’s important to get the skin clear as early as we can. I don’t know if, where you are, you’re doing any e-consults or reviewing images, but at Yale now, we do have a pediatric dermatology e-consult program where pediatric providers can take photos, they get uploaded to the chart, they send their questions, and then we review them. Oftentimes it’s something that we can give recommendations for, which the pediatrician can carry out. Then if that doesn’t work, we have a contingency plan that they can come to our clinic, or for somebody who is more severe, we can fast-track them in to get to see a dermatologist.These things are starting to pop up. Do you have anything like that?

Yes. We do have a robust e-consult program, not specifically for pediatrics, but pediatricians are involved and can be included in that. We also are looking at an e-visit type of format. For patients, I may have seen some patients for something else—molluscum, what have you—but now they have atopic dermatitis, they might send me a question, and then we have to figure out how to code and bill for that to create that access. You’re right, e-consults have been a great model; a lot of white papers have been written about that to improve access and get people care much faster. And then sometimes, because it decamps, it allows us to say, hey, this person doesn’t need to be seen tomorrow, they can try this and then be seen in a month or so. We have a visit for them. All of those things create access and, I believe, provide much better patient care.

For the referring pediatricians, it’s great too because you learn, and then the next time they see a patient with something similar, they can remember or even look back at what the plan was and try that first. That may, like you said, distill out the kids who need to be seen. The wait times are not as long, etc. I have, in my community, pediatrician friends who have my number. There are papers written about pediatric dermatologists, how much time we spend on off-hours managing other patients. But it’s nice, too, if you have a dermatologist in your community who you have a relationship with and can have a little back-and-forth, or someone to help get a patient in and all that. I find it nice to connect, and it’s a way to get kids help when they might not have it.

Yes. I know people complain there’s a lot of burnout with EMR [electronic medical record] iteration, but I think when used appropriately, it can be a powerful tool. What I try to help other physicians understand is as burdensome as they may feel that it is, imagine those patients would try to contact you some way. If it weren’t on your MyChart or something like that, they would be calling you. This allows you to manage and have some agency about when you do it or what have you; you imagine at the end of your day looking at 30 telephone messages that haven’t been responded to. It’s about a worldview…. So there are clear issues that we need to manage, but also we need to think about how we can provide better care and manage some of it in a way that’s tenable for us.

Expert dermatologists discuss the role of a multidisciplinary care team in treating pediatric AD and the modes of communication between specialists and pediatricians.