Joshua Zeichner, MD

 Thanks so much for that great discussion. It shows how important it is for us to have effective treatments to address the skin itself as well as quality of life in our patients with atopic dermatitis, especially the children. Let’s go one by one to everybody in the panel. I’d love to hear one parting thought. What message do you want to give our audience about treating atopic dermatitis?

 My departing take-home message would be to inspire, encourage, and empower all the dermatologists and pediatric dermatologists out there to work to treat their patients’ atopic dermatitis. It’s a miserable condition to have. We were limited in our options in the past, but we now have some really good options that can make a big impact on patients’ lives. If you aren’t comfortable with some of the therapies that are now available, try to work to get comfortable or encourage your patients to see somebody who is comfortable, because we have too many good [treatment options] to leave patients suffering with atopic dermatitis.

 I’d put a plug in for education. About 90% of what we’re doing in our atopic dermatitis visit is education. There’s a lot of information that patients have to digest, and a lot of misinformation out there. They’re often patients who have invested a lot in learning about their disease and options, so being able to take the time to help them think through it is important. Even now, when we have all these amazing new treatments, education is still a critical foundation building block of care for atopic dermatitis.

It’s exciting now. The question is, what do we do when our toolbox has so many tools? It’s overflowing. That’s where another exciting aspect of the next phase of this is: personalized care. Are we going to be able to get certain things in our hands, such as biomarkers, that help us filter through all of these immunologic therapies at the level of our patient? That’s going to be cool. Because it’s hard sometimes to decide between choices, especially when you’re in the psoriasis realm, where maybe we’ll be in 5 years, when there are so many options available to us both topically and systemically.

 When it comes to dermatologists treating pediatric atopic dermatitis, it’s great that we have all these therapies. In particular, we’re seeing revolutions in moderate-to-severe disease. But I encourage everyone out there to understand all the different ways you can look at moderate-to-severe disease, and make sure that you’re capturing your patients, understanding the severity, talking with the families, and seeing who might benefit. Sometimes it isn’t just a quick glance at the skin, and it goes much deeper than that. Understanding all the different domains of activity that we think about with this disease is important.

 Brittany, what about you? What are your parting thoughts?

 I agree with everything that has been said. We always have to remember to treat the patient in front of us and not so much the disease. The other thing is that we all went into medicine to help people, and there’s a lot of burnout, extra [responsibilities], paperwork, EMR [electronic medical record], and all these things. Sometimes these conversations take longer, which can be hard in a busy clinic. But there’s nothing like taking somebody who isn’t sleeping, isn’t going to school, and is miserable, and making them better. It’s so rewarding. Those are the patient interactions that keep you going and make you want to go to work. It might take a little more time, but you’re reaping the rewards too. It’s so fun, and people are so grateful. Remember that if you’re feeling bogged down by all the other stuff.

 Whenever you write a prescription medication, you have to weigh the potential risks with the potential benefits. Sometimes when we’re writing prescription medications, especially for younger children, that can be scary, especially if you aren’t a pediatric dermatologist. But the latest generation of medications that are targeted toward the specific type of inflammation that we see in atopic dermatitis are so safe. As we weigh that potential risk with the potential reward, the reward wins out, and a lot of these cases demonstrated that. That’s the art and science of medicine.

I want to thank everybody so much for this lively discussion. We had a great panel. Thank you so much to our audience. Hopefully, you learned a couple of new tips and tricks about treating pediatric patients with atopic dermatitis.

Videos

Joshua Zeichner, MD; Brittany Craiglow, MD; Elizabeth Swanson, MD; Vikash Oza, MD; and Raj Chovatiya, MD, PhD, provide take-home messages for dermatologists treating pediatric patients with atopic dermatitis.

Take-Home Points

 How do you have the conversation with parents about the short- and long-term risks associated with biologics? How does that impact your decision-making and the shared decision-making to start a younger child, or even an older child, a 12-year-old, on a biologic?

 The chronicity of the disease is one of the big things that’s oftentimes missing from the discussion. I’d like to put it front and center that this is a chronic disease. It isn’t an acute thing. We’ve seen what it has done in this particular circumstance, but it’s possible that this might be something that changes some time from now. The bottom line is that the reason we want to think about a whole-body option for treatment is to manage this longitudinally while balancing short- and long-term adverse effects, both of which are very favorable in the case of biologic therapy.

There are obviously a couple things you want to mention in the short run generally across age groups. You’re obviously thinking about some of those eye adverse effects, conjunctivitis in particular. Injection site reactions are another one in the early treatment course that generally seem to be persistent across different groups. Obviously, most of the things on that list tend to be less common but are possible, everything from herpes to some of the less common eye adverse effects.

In terms of long-term adverse effects, adults have accumulated the most long-term extension data, but we’re still past a year in terms of what has been out for adolescents and younger patients. I like to emphasize that this has been out for a while and we’ve been studying it for a while. There are data that are continuing to accumulate, not even officially related to a trial but also real-world data that people are publishing. Sometimes I find that people respond really well to talking about how long something has been out there, how much it has been studied, and how much people continue to put out there. That helps to balance that discussion with my patients.

 Every family wants to know, how long does he or she have to be on it? And I always think, if you were diagnosed with hypertension, are you asking your physician, “How long do I have to take metoprolol?”

 That’s a hard question, especially if you don’t do this a lot, because we don’t know the answer. To address it, I say, “For as long as he or she needs it. We’re probably looking at this for the foreseeable future because this is a chronic disease, but we’re going to re-evaluate.” Nobody likes to hear that this is for forever. For some people, it might be forever. But also in pediatrics, some of these children are going to get better over time. We see that less often in the children who are more severe who we’re treating, but we don’t know. Maybe shutting down this signal for a period of time hits a reset button in the immune system.

I usually say, “We’re going to do this for the next many months. If we come to a point where Johnny’s doing great and you aren’t even having to use topicals in between doses, and we go through a couple seasons like that, then maybe we’ll re-evaluate and think about spacing out injections a little.” Leaving the door open for them is useful. Because the psychology of forever doesn’t feel good to people. It’s helpful to acknowledge that and say, “I feel comfortable with this therapy, and I want your child to be better. If you need it, cool. If there comes a point where you don’t, even better.”

 It’s important to set the expectation of more than a year, because some people assume it’ll be a couple of months, and there are very few, if any, patients where that’s the scenario in the age groups and indications that we’re treating. Setting that up is important. The last part is one of the most interesting and pressing questions for us as pediatric dermatologists, especially as you’re moving into a younger age group: When could we pull off? How do you pull off? Over what period of time? For a lot of inflammatory conditions, I want to see good disease control for 6 months or a year before I’m even contemplating that, but that’s just a gestalt and not based on any empirical data.

Atopic dermatitis specialists discuss how to have a conversation with parents about risks of biologics and how to answer questions about length of therapy.

Case 3 Continued: How to Have Conversation About Risk of Biologics and Length of Therapy

 Let’s open this up to the entire group and talk about this case. What are your initial impressions?

 And then some. That’s a lot going on in 1 case. Unfortunately, it’s probably similar to stuff we’ve all seen before. Cases like this break your heart because this is everything we talk about. It’s the full burden of disease: the mental health, the social aspect, the actual health, the polypharmacy—everything top to bottom.

 I’m wondering what took her so long to get to dermatology. In some places, there’s poor access. But also, pediatricians often feel either that nothing has helped their patients, so they send fewer patients, or that they’ll grow out of it eventually. When we see patients like this, part of our job is to make sure our letter gets back to the pediatrician, or to call them and say: “There are options now. If you ever have a kid like this, please call me. I don’t want them to suffer.” Because these kids shouldn’t be floating around out there. They need to see somebody who can treat them appropriately.

 It’s tough across ages when the original gatekeepers are saying this is nothing or just a skin thing and not a big deal, or that there probably isn’t much you can do after lotions and potions and stuff. Both of those are huge gaps in education. Obviously, that’s one problem. But then there’s also the fact that you’re left with patients swirling around the ether and not making it to a place where they can get better.

 Then when the discussion begins about how to help her and how to fix this, she’s 12, so there are options that exist for her above and beyond topical corticosteroids, TCIs [topical calcineurin inhibitors], and crisaborole. She’s now eligible for topical ruxolitinib, although that’s approved for less than 20% body surface area. I forget if they mentioned the exact body surface area in the clinical vignette. That might be an issue for her, because it seems she has pretty bad atopic dermatitis. Then I’d have a good discussion about dupilumab. I’d also probably include in the discussion a little about upadacitinib, which is approved down to the age of 12. I’d hash out all the choices and do some shared decision-making with the patient and her family and find a way to make this better for her.

 All of you had a gut reaction or a knee-jerk reaction that we need to get this child better right away. But for each of you, what’s your opinion? Are we going to systemic medications right away? Are we adjusting her topicals? What’s your approach in putting together a treatment regimen for this patient?

 I love how Lisa laid it all out there. I very much love doing the same thing as well. Because in many ways, it’s a bit like a “Choose Your Own Adventure” book, because you don’t know what’s important for the individual patient and their family, what they rank as risk vs not risk, or what the route is. Rather than making that decision for them, I like to make them an active participant in the process.

In this circumstance, as Lisa put it, an oral therapy could definitely be valid. This patient had an oral systemic medication previously, so that’s theoretically a possibility. The biologic is another great possibility. Topicals are another possibility as well. But in this circumstance, without knowing much else about the body percentage area, moderate, etc, a systemic oral therapy is definitely warranted, given the huge burden of disease that we see here.

 In terms of the systemic [therapy] available to them, probably for most of us, where we’re practicing, it’s going to be dupilumab because they haven’t failed a systemic and that’s on the indication before something like upadacitinib, which theoretically would be available to her if she had failed something like dupilumab. That’s the balance that you weigh as the clinician. But clearly, this is somebody who’s greatly impacted in terms of their quality of life. It clearly is past that threshold. I’ll start patients on a systemic the first time I meet them. It isn’t the majority. The majority is sometimes reassessing and seeing compliance with short-term follow-up. When patients have a very clear story of failed therapies and [are] struggling, sometimes we start a systemic therapy off the bat.

 Take me through your conversations with the patients on the impact of atopic dermatitis on quality of life, especially in someone like this, who’s suffering so much.

 It’s acknowledging that what they’re experiencing is something that we see experienced by many children with moderate to severe eczema. It’s one of the comorbidities, just like a food allergy or asthma. That’s true of so many of our conditions, when we’re talking about a patient who has hidradenitis suppurativa or alopecia areata. We expect this to have a big impact on you, and in terms of your quality of life. The experience that she’s had isn’t her fault. Her scratching isn’t her fault. Her lack of compliance isn’t necessarily her fault either, when she’s had a disease where she’s had suboptimal care and hasn’t responded so well.

Normalizing that aspect is important because it helps them realize they’re seeing the burden of the disease in their own child. Hopefully, with the right therapies, they’ll see that they aren’t seeing it as much. But there’s also a big role for psychiatric care and mental health support. We think these medicines will drastically improve that, but children who have been suffering from these things can have that mental health aspect across multiple axes in their life, and having support there is important. Normalizing that that’s also a relationship that benefits children with chronic disease is also helpful.

Expert pediatric dermatologists provide impressions on the case of a 12-year-old girl with atopic dermatitis.

Case 3 Continued: Impressions

 Here we have a 12-year-old female patient who presented to her dermatologist with dry, itchy patches on her arms and legs. She admitted to suffering from frequent disturbed sleep, which caused her to miss school and underperform on exams. She also admitted to wearing long-sleeve shirts in school, even on hot days, to prevent her friends from seeing the scratches on her arms. Since her diagnosis 3 years ago, she stopped playing soccer and going to the pool in the summer and has been diagnosed with mild depression.

In terms of her medical history, she was being treated by her primary care doctor for the past 3 years. At the age of 9, she was very active and went outside, but she’d come home with red and dry skin. Her mom would treat her with emollients and moisturizers, applying them 2 times a day after showering. At the age of 10, her flares became worse, triggering her mom to take her to her primary care physician. She was then prescribed hydrocortisone 2% daily. The hydrocortisone 2% was effective for 6 months, but then lacked efficacy.

Over the next several years, she was put on numerous topical steroids and then was switched to pimecrolimus 1% cream, which brought on multiple adverse effects. She was also prescribed prednisone to take care of the flares when they occurred, but she suffered many unwanted adverse effects from it and felt it caused more harm than good. Her mom admitted to also giving her Benadryl when the itching was bad because she didn’t want to see her child in pain, but she suffered from excessive sedation.

In terms of her past medical history, she suffers from depression. For her social history, she’s a middle school student currently on academic probation because of failing classes. She’s on sertraline 25 mg daily. In terms of other clinical workup, all laboratory values are in normal range.

Joshua Zeichner, MD, reviews the case of a 12-year-old girl with atopic dermatitis.

Case 3: 12-Year-Old-Female With Atopic Dermatitis

 How do you guys address the idea of taking a medication that’s given by an injection for a little child? For adults perhaps it’s an easier conversation, but it’s definitely a challenge when you’re dealing with children.

 I’m sure we all have different techniques. Most of the time, we’re doing the injection the first time in our office, so we try to go through some of the techniques, and obviously we’re teaching at the same time. For those of us in pediatrics, there are several things that we do. The first is distraction. My kids barely know when I’m home because they’re constantly being distracted by a screen, so the power of the screen is very important. It’s helpful to have them in a comfortable position and distracted, and then even held in a certain way. As an adult, you’re just used to them lying on the table and you inject it. But in kids, there’s what we call the comfort hold: being held in the parent’s arms, where they’re secured in certain ways and the limb is secured, but they’re also being held by a parent, which is comforting for a child.

There are also ways that we can reduce pain, such as a topical anesthetic, having EMLA [lidocaine, prilocaine] sitting there for an hour before you inject. Some children seem to do a little better with ice sometimes, too. Making that available and doing it in the office for the first time to show them is important. Some kids will even balance their own risks and benefits. They realize that the injection does hurt for that moment, but particularly those who have severe atopic dermatitis, if they’re in a certain age group, they’ll realize the impact that it’s having on them. When they see the improvements, you get buy-in sometimes that way as well.

 To that point, I’ll often tell children, especially 5- to 8-year-olds who are old enough to understand: “Yes, the shot hurts. But that 3 seconds of ouch is worth feeling better every other second of every other day, so put up with it for this 2 or 3 seconds, and then you’re going to feel so much better the rest of the time.” In the younger kids, the 2- to 4-year-olds, when they start Dupixent, or dupilumab, I’ll often have them sit in their parent’s lap, facing their parent in a hug. Then we’ll give it either in the thigh or the arm, whatever is most accessible and easiest to do.

The biggest issue that I’ve noticed in starting to use the medication in younger patients, the 2- to 4-year-olds, isn’t the first shot or the second or third, but after that. They start to have anticipation. They know that the past 2 or 3 times they’ve come to this office, they got a shot. I’d be interested in whether other people on the panel are dealing with that, and how, because I find that has become a little harder. At that point, the parents have pretty much bought into the process because they’re seeing the impact that it’s having for their child, and they like that very much. But it gets a little harder with the children themselves, because they’re anticipating the ouch factor.

 I agree 100%. I like to try to get families to do it at home, because for the child, with the car ride, the waiting room, and the examination room, the anxiety is building. But a lot of parents don’t want to be the one to do it. I also completely understand that. I’ve recently started asking, “Is there anyone in your circle who might be able to do it?” One of my patients has his aunt doing it. For another one, their neighbor used to be a nurse. It doesn’t even have to be a medical person, just somebody who’s helpful because they’re a little more comfortable with it. Not the parent, but somebody else, so you can avoid all that buildup for this small thing.

Lisa, to your point, acknowledging that it hurts is important. We have this tendency, especially parents, to say: “Oh, it isn’t that bad. You’re OK.” But with kids with anxiety, it’s important to say, “Yes, this is uncomfortable, but you can handle it,” for those who are 6 years old and up. Making sure it’s room temperature is also important. I always tell the families take it out of the fridge the night before. Put the reminder in your phone and take it out the night before so that when you’re ready, you’re ready. That prevents everyone looking at it on the kitchen counter, counting down the hour. Dupilumab is fine at room temperature for 2 weeks, so if you don’t do it that day, you do it the next day. Work with them to figure out ways to make it easier. In some cases, it’s still going to be hard, but we can make it work for the majority of them.

 This is such an interesting discussion. There are so many social factors that we have to take into consideration. This is the art of medicine.

Joshua Zeichner, MD; Brittany Craiglow, MD; Elizabeth Swanson, MD; and Vikash Oza, MD, address techniques for injectables when treating pediatric patients with atopic dermatitis.

Case 2 Continued: Addressing Injectable Medication in Children

 What about combination therapies? How do you guys like to put together your combination routines? Steroids, nonsteroids, emollients—what are you commonly recommending to your patients?

 It depends. When we’re seeing them, especially the first time, usually the patient is in a flare. As we talked about before, this is a lot of times where I’m using a topical steroid. In terms of how long do we tell them to treat for, I’ll often say, “We treat to the point when you feel that the skin is clear, and then for several days even beyond that, whether it’s 3 to 5 days.” I give most patients an average window. That might be 10 to 14 days of therapy. Then a lot of times, there’s a cool-down period where you’re at risk of reflare, so you could potentially then go to a nonsteroid-based therapy that you’re using every day on those hot spots, with your gradual goal of seeing if you can adopt the maintenance regimen 2 to 3 times a week.

We have finessed in other ways, such as maybe a couple steroids on the weekend and the nonsteroid during the week. We have different ways of playing it out. But giving them a road map of what to expect and where we want them to be is helpful. An action plan or road map is important, and recognizing problems, such as the burning sensation that Brittany talked about. That’s when you’re putting it on red-hot inflamed skin. That’s going to be a problem. Other tips include keeping the tacrolimus cool in the refrigerator, which might reduce stinging. But a lot of times, it’s because we’re trying to use it on very inflamed skin.

 At what point are you having a conversation with the patient or the patient’s family about moving from topicals over to systemic medications or biologics? How do you make that decision? How do you broach it to the families?

 We don’t make it ourselves; we make it in concert with the family. That’s the whole concept of shared decision-making. We decide when we think we’ve done our due diligence—such as thinking about contact dermatitis, like in this case—and have had a follow-up where we feel like there has been good compliance. The reality is that there are all these new markets coming to the table because some of these topical steroids aren’t that effective. There might be ones that are going to have superior efficacy that we’ll luckily be able to go through and help moderate patients.

Then we weigh risks and benefits, talking with patients about the reality that was just talked about and an injection that makes it potentially once a month. We talk about how frequently some of the adverse effects are with dupilumab and how we have experience in managing them. We talk about the impact factor that it’s already having in this child right now, with bullying, potentially internalizing behavior issues with depression and anxiety, and the great impact that can have without addressing it early. Once we’ve done all we felt we could do for the patient but they still fit into the moderate to severe category, we let them know that we have medicines that are safe, approved for their age group, and could make a significant improvement.

 I completely agree. You want to make sure that you’re eliminating other diagnoses that may be complicating the picture. Then, for me, it’s about how this is affecting the way the child or the patient is interacting with the world. If it’s doing that in a meaningful way, such as if they aren’t going to school or sleeping well, and they don’t want to raise their hand because they’re afraid that someone’s going to see their skin, and they’re doing all the right things, then it’s time to move on.

When the choice was cyclosporine, it was a bit of a different conversation. This is a systemic medicine. It isn’t a vitamin. There are some potential risks. The risks are low, but they’re there. Every family has a different level of risk aversion. There are a lot of questions, and it’s important that we make this decision together, as Vikash said. Sometimes I’ll say: “We know from the data that most people are going to be close to where they’re going to be by 3 or 4 months with dupilumab.” We try it for 3 or 4 months, and then we can see how things go.

The injections can be hard. They usually aren’t a deal breaker, but every so often, if a child is needle phobic, that can play in, too. It’s a 2-way conversation, and weighing risks and benefits. But if it’s potentially changing the child’s trajectory, these children are so obvious. They’re missing school or getting infections. Then there are children who maybe aren’t waking up scratching every night, but when they flare, they’re missing school or aren’t able to concentrate as well. These little things can add up to move the needle for them, and that’s important to keep in mind.

Expert pediatric dermatologists discuss the importance of combination therapy and shared decision-making when treating pediatric patients with atopic dermatitis.