Lisette Hilton

Pediatricians might know that food allergy and atopic dermatitis (AD) often coexist. What they might not realize is that food allergy rarely is a primary cause of AD, or eczema, according to Pooja Varshney, MD, clinical assistant professor of Pediatrics at Dell Medical School at the University of Texas at Austin and a pediatric allergist at Dell Children’s Medical Center, Austin.

“We know that AD and food allergy often travel with each other, along with other allergic conditions like rhinitis and asthma. The question often presented to pediatricians is whether a food allergy is causing a child’s AD or causing it to flare,” says Varshney, who spoke on the topic in July during the Society for Pediatric Dermatology 44th Annual Meeting in Austin, Texas.

Cow’s milk, hen’s egg, peanut, wheat, soy, tree nuts, fish, and shellfish are responsible for more than 90% of food allergy in children.

 Nearly 40% children with moderate-to-severe AD have immunoglobulin E- (IgE-) mediated food allergy.

Pediatricians should keep in mind that patients with AD, especially those with more severe disease, are likely to have or develop food allergy, according to Varshney, and it’s important to identify whether AD patients have food allergy with IgE-mediated symptoms, which is seen soon after eating foods. “Ask food allergy screening questions in children that have AD, certainly if it is moderate-to-severe,” she says. This is a test of the emergency system. Please be advised that in the case of a real emergency

However, whether foods are actually triggering AD can be much harder to determine. A history of eczema flaring soon after ingestion of a food, either through the child’s diet or through the diet of a breastfeeding mother, is difficult to differentiate from the natural waxing and waning of AD disease.

There isn’t much evidence to support eliminating foods from moms’ or children’s diets to help their eczema improve, and elimination diets have real risks, according to Varshney.

“The risk-to-benefit ratio is really changing. Recent studies have shown that elimination of foods from a child’s diet rarely improves AD and [a child] very well may have increasing risk of developing anaphylactic food allergy if he or she avoids a food unnecessarily. This is particularly true of a child who was previously able to eat the food without any immediate or anaphylactic symptoms,” Varshney says.

The recommendation to avoid unnecessary elimination diets is a paradigm shift in thinking, Varshney says. A recent guideline published by the National Institute of Allergy and Infectious Diseases (NIAID) helps guide pediatricians and others in the care of young children who have AD in how to introduce foods. The current NIAID guidelines help pediatricians identify patients that may most benefit from allergy evaluation, as well as guide patients at no or low risk for peanut allergy.

“I think a main take-home of the guidelines is if a baby has mild-to-moderate AD, we really do not need to test before food introduction. We really want these assessments and conversations to be happening early-at the 4- to 6-month well checks,” Varshney says. “In those infants who have severe AD, testing is recommended before giving the baby peanut. We really are looking to identify babies with severe AD or those who already have a food allergy, particularly to egg, as they are at highest risk of peanut allergy but also stand to benefit most from early introduction if not allergic. That’s when early testing is suggested.”

Varshney also points pediatricians to a recent American Academy of Pediatrics (AAP) guideline looking specifically at nutritional interventions for prevention of atopic disease. The guideline reports no benefit from using hydrolyzed formulas or changing maternal diet for the development of allergy, according to Varshney.

 It’s a field that’s constantly evolving, she says.

The diagnosis of food allergy tends to be more reliable when it’s based on and guided by a thorough history and physical exam. Whereas allergy testing is useful to confirm IgE-mediated food allergy, it has its limitations. Food IgE panels are not recommended because they can result in misdiagnosis of food allergy, Varshney says.

There’s also unnecessary and potentially harmful testing going on. Varshney says some naturopathic and nontraditional providers utilize inappropriate or disproven testing, including food immunoglobulin G (IgG) panels and muscle testing. These tests are not recommended and often lead to unnecessary elimination diets. Pediatricians need to firmly but gently educate their patients about the pitfalls of such testing and risks of inappropriate elimination diets in children, she says.

Testing is most useful when pediatricians determine or suspect that a patient has an immediate or IgE-type food allergy, Varshney says.

“All patients with a suspected food allergy should be seen by a board-certified allergist trained in food allergy. Whether the pediatrician orders any blood testing or defers the full evaluation to the allergist is dependent on the physician. Consultation with an allergist allows for additional testing like skin prick testing, food challenge, as well as follow-up because we know that certain food allergies-particularly milk and egg-are commonly outgrown,” Varshney says. “Testing can help determine the course of a particular child’s food allergy. Peanut allergy is less commonly outgrown but is outgrown in about 20% of kids, so we do need to follow these kids.”

Pediatricians should recommend that patients with IgE-type food allergy strictly avoid the food until seeing the allergist and consider prescribing injectable epinephrine in case of a severe reaction.

Varshney says there are a few theories about why eczema and food allergy often coexist.

The idea of the “atopic march” is one. The theory describes the progression of allergic disease seen in many children who have allergies, starting with AD and food allergy early on. Then these children typically go on to develop other allergic conditions such as allergic rhinitis and allergic asthma.

Another idea has to do with sensitization through the skin. So, children with a defective skin barrier, which is a big part of AD, are more susceptible to allergens, including food allergens, that penetrate the skin and activate the immune system to develop an abnormal or allergic response to food.

Still other theories revolve around the thinking that these conditions aren’t actually a cause-and-effect but rather travel together, perhaps due to genetic predisposition.

“We know genetic abnormalities and certain mutations exist with both those conditions. So perhaps the conditions are just different expressions of a particular patient’s genetic predisposition to developing allergic disease,” Varshney says. “This is an active area of research looking at how early intervention for AD may reduce the rate of food allergy development.”

That includes ongoing research looking at whether starting treatments such as dupilumab early in life can help prevent or halt the atopic march, she says.

In the meantime, attention to the skin barrier with thick emollients and moisturizers is a low-cost and low-risk intervention that pediatricians can recommend early on. It might be an intervention to help prevent the atopic march for at-risk infants, according to Varshney, but that’s not yet clear.

Dr. Varshney discloses the following: Food Allergy Research and Education, clinical network grant, principal investigator and medical director; Aimmune, principal investigator; DBV Technologies, principal investigator.

1. Bergmann MM, Caubet JC, Boguniewicz M, Eigenmann PA. Evaluation of food allergy in patients with atopic dermatitis. 

2. Eigenmann PA, Beyer K, Lack G, et al. Are avoidance diets still warranted in children with atopic dermatitis? 

3. Du Toit G, Roberts G, Sayre PH, et al; LEAP Study Team. Randomized trial of peanut consumption in infants at risk for peanut allergy. 

4. Fleischer DM, Bock SA, Spears GC, et al. Oral food challenges in children with a diagnosis of food allergy. 

5. Togias A, Cooper SF, Acebal ML, et al. Addendum guidelines for the prevention of peanut allergy in the United States: report of the National Institute of Allergy and Infectious Diseases-sponsored expert panel. 

6. Greer FR, Sicherer SH, Burks AW; Committee on Nutrition; Section on Allergy and Immunology. The effects of early nutritional interventions on the development of atopic disease in infants and children: the role of maternal dietary restriction, breastfeeding, hydrolyzed formulas, and timing of introduction of allergenic complementary foods. 

7. Natsume O, Ohya Y. Recent advancement to prevent the development of allergy and allergic diseases and therapeutic strategy in the perspective of barrier dysfunction. 

8. Kim J, Kim BE, Leung DYM. Pathophysiology of atopic dermatitis: clinical implications. 

Articles

Recommendations for whether to test for and treat food allergy in the setting of atopic dermatitis have changed.

Food allergy: A trigger for atopic dermatitis?

Maternal and paternal genetics, immune function, and socioeconomic factors influence atopic dermatitis (AD) risk in offspring, and whereas studies looking at how parents impact their children’s risk for the common skin disease tend to demonstrate a greater maternal influence, more studies are needed to examine how paternal genetics, lifestyle, and more might increase or decrease AD risk in their children, according to a review published in 2017 in 

“There appears to be a larger maternal factor than paternal in many of the studies reviewed. For example, maternal smoking doubles the risk of AD development, but apparently not paternal. To a certain extent, fathers are ‘off the hook,’ but it is probably not that simple. Practical aspects such as recall bias in filling out the surveys could mean that paternal risk factors were overlooked, and some studies found evidence that if either parent has AD, the risk is increased in offspring,” says study author 

, clinical assistant professor of Dermatology and Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago. Illinois.

There is a body of research that suggests fathers and mothers with histories of AD have similar chances of passing the disease to their offspring. One example: A US study of more than 1000 mothers’ infants found that of children who developed AD in the first 6 months of life, 26% had fathers with a history of AD versus 32% with mothers who had a history of the disease-a difference that was not statistically signficant.

Other researchers studying 285 families, each with 1 parent who had AD, found 58% of children developed AD if they had a father who had the disease versus 57% of children who developed it who had mothers with a history of AD.

 Authors of still another study of 4089 children followed from birth to 4 years found one-third of children were diagnosed with AD. Nearly 38% of those had at least 1 parent-with equal likelihood of it being a mother or father-who had a history of AD.

When they reviewed epigenetic research, Lio and colleagues found AD’s heritability involves multiple alleles on separate chromosomes. Mothers’ and fathers’ genetic makeups likely both exert influence on offspring’s development of AD, but studies to date support a mother’s genes have a stronger impact, the review authors report.

Socioeconomics, occupation, maternal/paternal lifestyle

Lio says there were 2 things that surprised him when doing research for the review.

“The first was that having a higher socioeconomic status is associated with a higher AD risk. This is interesting because many conditions seem to affect lower socioeconomic groups more, presumably for a number of health and lifestyle-related reasons,” Lio says. “The second was that higher education level in mothers was associated with a higher risk of AD. I have long felt that our AD patients seemed to be a particularly intelligent group, and this is a fascinating association.”

Maternal influence seems to outweigh paternal impact when it comes to educational differences. Data suggesting that parents with higher education levels were more likely than parents with low education levels to have kids with AD was statistically significant only for more educated mothers.

Although research is lacking about whether fathers’ occupations impact their offspring’s AD risk, there is data suggesting that working pregnant women are more at risk of having children who develop AD than nonworking pregnant women.

Maternal smoking, prenatally and postnatally, and maternal alcohol consumption during pregnancy both have been shown to increase AD risk in offspring. However, whether paternal smoking or alcohol consumption impact AD risk isn’t clear. One study showed that paternal alcohol consumption had no influence on AD risk in children.

The dream of “precision medicine” is finally starting to come into fruition, according to Lio.

“With new therapies such as targeted biologic medications for AD, we are beginning to more deeply understand the complex pathogenesis of the disease. Along with this, I am hopeful that we will be better able to tease out maternal and paternal factors and, perhaps most importantly, explain why they have the effects that they do on the children,” Lio says. “To some extent, this research is useful as it can also help guide mechanistic understanding of the disease, as well as allow for better counseling. Knowing that certain lifestyle issues like smoking and alcohol use can increase the risk of development of AD-a disease with significant morbidity and sometimes shocking associated costs-should help guide public policy programs to minimize such risks.”

Pediatricians should consider asking about family history of AD in both parents to help frame some of the risk, according to Lio.

“Reviewing the behaviors that are associated with increased risk such as alcohol use and smoking is probably important,” Lio says. “We also have some evidence that taking probiotics during pregnancy may decrease the risk of developing AD, and evidence that moisturizing daily starting in the newborn period may also decrease the risk of AD. Together, these may help identify higher-risk families and promote potentially helpful approaches to minimize disease.”

1. Vaughn AR, Sivamani RK, Lio PA, Shi VY. Paternal vs maternal factors in childhood atopic dermatitis. 

https://insights.ovid.com/pubmed?pmid=28614111

2. Moore MM, Rifas-Shiman SL, Rich-Edwards JW, et al. Perinatal predictors of atopic dermatitis occurring in the first six months of life. 

3. Uehara M, Sugiura H, Omoto M. Paternal and maternal atopic dermatitis have the same influence on development of the disease in children. 

4. BÃµhme M, Wickman M, Lennart Nordvall S, Svartengren M, Wahlgren CF. Family history and risk of atopic dermatitis in children up to 4 years. 

5. Wang IJ, Wen HJ, Chiang TL, Lin SJ, Chen PC, Guo YL. Maternal employment and atopic dermatitis in children: a prospective cohort study. 

6. Wada K, Konishi K, Tamura T, Shiraki M, Iwasa S, Nagata C. Alcohol intake during pregnancy and offspring’s atopic eczema risk. 

Pediatricians should consider family history of atopic dermatitis (AD) in both parents to help frame the risk for their offspring.

Paternal factors also affect children’s risk for AD

Positive results from studies looking at pipeline treatments for common warts might give pediatricians hope that something simple and nondestructive would magically make warts disappear-never to return.

In June, for example, Verrica Pharmaceuticals (West Chester, Pennsylvania) announced Phase 2 trial results showing 51% of subjects achieved complete clearance of common warts when treated with VP-102, a topical solution of 0.7% cantharidin in a single-use applicator.

Although the trial suggests VP-102 was well tolerated with no serious adverse events, treating warts with cantharidin and other options brings up the old wart conundrum: Is treating warts worth the risk when most will vanish on their own and most treatments are only temporary? This is according to Bernard A. Cohen, MD, professor of Pediatrics and Dermatology, Johns Hopkins University School of Medicine, Baltimore, Maryland.

Cohen and coauthors did a retrospective chart review of pediatric patients with common warts in an outpatient setting, published in 2015 in 

. Most of the 214 patients surveyed received some form of therapy, but it wasn’t clear that any form of treatment altered the course of their warts. The researchers found that warts resolved in 65% of children by age 2 years and in 80% by age 4 years, regardless of treatment.

The findings suggest that counseling without aggressive destructive treatment is reasonable for managing warts in most children, the authors concluded.

“The bottom line is we didn’t find anything that worked better than placebo,” Cohen says. “I think it’s very important for pediatricians to know that still, at this point, it is unclear if anything works better than placebo to make warts go away permanently.”

To best guide patients and families about whether to treat or not to treat warts, pediatricians should know about the natural history of common warts, according to Cohen.

Most important: Risk of serious complications from warts in otherwise healthy kids is negligible. Yet many treatments for warts are destructive and painful and are more likely to cause complications than the warts themselves, he says.

Still, Cohen notes that children’s quality of life can suffer when their warts are in places that are visible to others. “I’m not saying you should never treat warts. In fact, if I have patients who come in and the kids insist on it, we do a lot of conservative things,” he says.

Topical salicylic acid agents are among the first-line wart treatments Cohen recommends. He tells patients or parents to titrate the salicylic acid to the point that it doesn’t hurt and children don’t overdo do the treatment.

Years ago, Cohen would freeze, burn, and laser warts off, but says he isn’t a big fan of those options today.

“Occasionally I will use a nondestructive laser to make some of them smaller and less visible, but I do not do painful destructive things that could leave scars in children who cannot give consent themselves,” he says. “It’s important that pediatricians know there are palliative treatment options that are very conservative and not painful, which I think would be OK to do.”

When children are distraught about their warts, the goal is to recommend a nonpainful, not terribly destructive treatment to get the warts to dry out and shrink, while recognizing the chances of getting full resolution without recurrence is very low, according to Cohen.

“I had a kid the other day who came in and had one of these filamentous warts on the side of the nose. Everybody thinks they’ve got boogers in their nose falling out,” Cohen says. “I had the patient use a topical salicylic acid very gently to the point where it dries the wart, and I had the patient twist it and pull it off. It’ll probably come back but it might be a couple of weeks.”

Another option among nondestructive treatments is use of a topical retinoid. There are a number of over-the-counter products that Cohen says can make warts peel off a little bit, become flatter and subtler.

None of these have been shown to definitively make warts go away, but treating with salicylic acid, topical retinoid, or over-the-counter wart products might at least decrease wart size and visibility

There are also treatments that patients might have heard work but lack data to support that they do. Take garlic, for example. “What I tell people about garlic is it reduces the risk of it spreading among members of the same household if you wear garlic around your neck. Who wants to get near you if you have garlic around your neck?” Cohen says.

Pediatricians are in a position when they understand the natural history of warts to advise parents and patients about whether to treat and how best to do it for optimal results.

Part of the care includes having a frank discussion with patients and parents about how today’s treatments haven’t been proven to be better than doing nothing and could carry risks. If patients or parents still insist on treatment, pediatricians could recommend safer options, Cohen says. “I do think pediatricians can play a big role here by counseling patients and treating them with conservative treatments early on, if needed,” Cohen says.

Where warts might be more of an issue and worthy of a referral to a pediatric dermatologist or dermatologist is when children have symptoms related to the warts, including pain, or if the warts are on places such as the head or neck.

Pediatricians who elect to treat sexually active pediatric patients who have genital warts should consider a product such as imiquimod or Condylox gel (podofilox).

 “I don’t routinely use these for genital warts in young children unless they have symptoms from the warts,” he says.

In the end, understanding limitations of wart treatment is key for pediatricians, according to Cohen.

“I do think warts are a rite of passage of childhood,” Cohen says. “If you look at warts, the peak presentation is probably 8 or 10 years and around 16 years. I’m not saying that adults don’t get them but many kids who have had them and have had them go away have had an immunologic response and are not going to get them as adults.”

Cohen says there is some potential for wart products in clinical trials, including the cantharidin topical VP-102. Researchers studied subjects receiving VP-102 to day 84 with an additional period of follow-up through day 147.

“Secondary endpoints included the percent change from baseline in the number of treatable warts and VP-102 achieved a 51% reduction in the number of warts (28 of 55 warts) compared to baseline by Day 84,” according to Verrica Pharmaceutical’s press release. “The most frequently reported adverse events were application site reactions that are well known, reversible side effects related to the mechanism of action of canptharidin, a blistering agent...”

Cohen says with this and other pipeline wart treatments questions remain about whether the drugs work better than placebo and cure warts. He asks what happens when treatment is stopped. Do the warts come back, and what about in the years following treatment?

“We need to see the placebo-controlled trials that drugs work better than placebo and make the warts go away permanently,” he says.

Johns Hopkins residents are beginning to study whether children getting the human papillomavirus (HPV) vaccine has an effect on warts, he says.

1. Verrica Pharmaceuticals. Verrica Pharmaceuticals achieves positive topline results in Phase 2 clinical study of VP-102 in patients with common warts [press release]. Available at: 

https://investors.verrica.com/news-releases/news-release-details/verrica-pharmaceuticalsachieves-positive-topline-results-phase

. Published June 26, 2019. Accessed August 12, 2019. 

2. Kuwabara AM, Rainer BM, Basdag H, Cohen BA. Children with warts: a retrospective study in an outpatient setting. 

3. Moresi JM, Herbert CR, Cohen BA. Treatment of anogenital warts in children with topical 0.05% podofilox gel and 5% imiquimod cream. 

Many treatments for warts are destructive and painful, and are more likely to cause complications than the warts. A pediatric dermatologist advises what to do-or not do-for common warts.

Wart treatments vs placebo

Patients often suffer with much more than the skin manifestation of atopic dermatitis (AD), or eczema. Children with AD who present to pediatricians also may be more likely to experience decreased self-esteem, anxiety, bullying, and more, says Sasha D. Jaquez, PhD, a pediatric psychologist at Dell Children’s Medical Center and assistant clinical professor of Psychiatry, Dell Medical School, University of Texas at Austin.

Researchers analyzing health status data from 92,649 noninstitutionalized children, aged 0 to 17 years, found a “striking association between mental health disorders and AD in the US pediatric population. The severity of the skin disease alters the strength of the association,” they wrote in a paper published in 2013 in the 

Journal of Allergy and Clinical Immunology

Researchers studying psychosocial problems in adolescents with eczema found that 15.5% of teenagers with current eczema reported suicidal ideation compared with 9.1% of those without eczema.

 Another finding from that study: Boys with current eczema were less likely to have had romantic relationships than those without, according to the study in 

, researchers concluded that teasing, taunting, and bullying may represent an underappreciated source of psychologic morbidity in children and adolescents with eczema, acne, and psoriasis.

Pediatric dermatologic disorders, including AD, impact self-esteem throughout childhood, according to a study published in the 

International Women’s Journal of Dermatology

“In addition to the surgical and medical management of these disorders, clinicians can also take an active role in the assessment and improvement of the psychosocial impact of these skin disorders,” those authors concluded.

Pediatricians should be mindful that what they see with AD patients isn’t necessarily all that there is. They also should be cognizant about the risk for psychologic and social comorbidities, says Jaquez, who presented “Healing children one layer at a time: integration of Psychology in pediatric Dermatology,” in July during the Society for Pediatric Dermatology 44

“The pediatrician or dermatologist who might be the first to identify the problems but doesn’t have time to focus on this during treatment should refer to a psychologist who is trained to focus on how to get the child to be [his/her] best self despite the medical condition that they have,” Jaquez says.

Pediatric psychologists, according to Jaquez, see more than traditional outpatient mental health concerns, such as depression and anxiety.

“What sets child/adolescent psychologists and pediatric psychologists apart is that knowledge of medical conditions and working on multidisciplinary teams to address difficulties a child and family experience related to the medical condition, whether it is a diagnosable psychiatric condition or not,” Jaquez says. “This would include seeing patients for nonadherence; coping with and acceptance of a medical condition; behavior problems in younger children, which may affect their adherence; sleep problems; and anxiety and depression related to the medical condition.”

Atopic dermatitis is among the most common conditions that Jaquez sees in her practice.

“The skin is the first thing that many people see, and a lot of these kids with AD will go to great lengths to try and hide their skin. We’re in Texas where it’s 100 degrees, and I will see kids who are coming in with long-sleeved shirts and pants on because they don’t want their skin exposed for other people,” Jaquez says.

Jaquez says she helps pediatric patients with AD to accept their skin. “I talk with kids all the time about how their skin is just different. It’s not that it’s bad. So, we practice how they can tell other people that,” she says. “Other children often are afraid to play with children that have AD because they’re afraid that it’s going to be contagious. So, we practice with the child and also the parent about how to educate others about what it is and that it’s not contagious.”

Jaquez also works with children and families to find things that they’re able to do and enjoy doing and encourages them to do those things. “If they’re able to accept their skin condition and that it’s going to ebb and flow in terms of flares, then we can find time that they’re able to do the things they enjoy doing,” she says.

Part of the work involves overcoming perceived barriers. If a child who likes to swim doesn’t think he or she can swim in public anymore, Jaquez will work with the child and family to find a way that the child can safely swim, without putting them in a situation where people are going to judge them for the way that their skin looks.

Atopic dermatitis may not be a life-threatening condition, but it is chronic and visible. It’s important, Jaquez says, that pediatricians don’t ignore the stress a chronic condition can put on the child and family.

“One of my biggest messages to pediatricians is to be aware that this is really difficult stuff and that it’s OK for a family to need extra support,” she says.

Jaquez recommends that pediatricians have a psychologist on their team-onsite or as a referral source. If the psychologist is onsite, pediatricians should consider introducing the psychologist to the eczema patient and family early on, before they need or access mental support. That way, the patient and family know the psychologist and might feel more comfortable accessing the provider when they do need help, she says.

Pediatricians should consider referring AD patients to pediatric psychologists when pediatricians are concerned with patients’ mood, anxiety, or adherence to treatment.

“There’s a lot that patients have to do every day for their skin. I’ve talked to a number of patients where the doctor will tell me one medical regimen and I’ll check in with the family and they have heard it in a different way. Sometimes it’s just a matter of getting everybody on the same page and making sure they understand what they’re supposed to be doing,” Jaquez says. “I think if pediatricians are feeling frustrated with patients, that’s also a good time to make a referral because that means something is going on-even if they’re not able to pinpoint what that is.”

It’s important to keep in mind that parents might need psychologic support, too.

Researchers reported in a paper published in 2016 that AD in a child may lead to exhaustion, emotional distress, and depressive symptoms in parents.

 Identifying children with AD and their parents who need psychologic help may help to reduce emotional problems in these children and families, they wrote.

A big takeaway for pediatricians is that they should help to destigmatize mental health by helping families understand that AD and other diseases are stressful, and that just because there’s a referral to Psychology doesn’t mean that there’s a larger concern about mental health. Rather, they’re simply in a stressful situation, so it’s OK to have Psychology involved.

“Families fear what it means when they’re getting a referral to Psychology and can be very resistant to that. It helps when pediatricians talk about Psychology as part of the team versus ‘You’re getting a referral to Psychology,’ which often can have negative connotations,” Jaquez says. “Working together as a team we’re kind of able to peel away their layers and work toward healing the whole person.”

1. Yaghmaie P, Koudelka CW, Simpson EL. Mental health comorbidity in patients with atopic dermatitis. 

2. Halvorsen JA, Lien L, Dalgard F, Bjertness E, Stern RS. Suicidal ideation, mental health problems, and social function in adolescents with eczema: a population-based study. 

3. Magin P, Adams J, Heading G, Pond D, Smith W. Experiences of appearanceârelated teasing and bullying in skin diseases and their psychological sequelae: results of a qualitative study. 

4. Vivar KL, Kruse L. The impact of pediatric skin disease on self-esteem. 

5. Chernyshov PV. Stigmatization and self-perception in children with atopic dermatitis. 

Children with atopic dermatitis (AD) will go to great lengths to hide their skin. Here’s how referring them to a pediatric psychologist can help them be their best self, even with AD.

Healing both body and mind in atopic dermatitis

 was 17 years old when doctors delivered the life-changing news that he had acute lymphoblastic T-cell leukemia. Halfway through his senior year in high school, Meza would spend the foreseeable future at the Hyundai Cancer Institute at Children’s Hospital of Orange County (CHOC), California.

Meza says he felt like an outsider, at first. “Every time a child life specialist would come in, they’d bring you a coloring book or a puzzle. They didn’t have anything focused for older kids,” Meza says.

A positive person by nature, Meza still struggled with why cancer happened to him. He says the whole situation stunk. However, he didn’t have anyone going through the same thing or to talk with who was about the same age.

Things changed at CHOC in the middle of Meza’s 3 years of inpatient and outpatient cancer treatment. Children’s Hospital of Orange County started offering activities aimed at engaging teenagers and young adults. First it was simply a competition to encourage adolescents and young adults, known as AYAs, to get out of bed and walk the halls. Today, CHOC offers an assortment of social and educational activities through its Richard C. and Virginia A. Hunsaker AYA Oncology Child Life Program (Figure 1).

Meza, who at 23 is in remission and studies mechanical engineering and robotics at Embry-Riddle Aeronautical University in Prescott, Arizona, is among the developers, leaders, and mentors of CHOC’s AYA program.

Cancer incidence among AYAs is increasing, according to a recent editorial in 

, says that research in the last 15 to 20 years has revealed that adolescents have not had the same survival gains seen in the pediatric patients younger than age 12 years or older adults.

“There has been a lot of interest in the community at looking at this particular cohort of patients of adolescents to young adults, defined as from 15 to 39 years of age. It incorporates the wide range of oncologic malignancies that happen during the time frame,” Frediani tells 

Whereas the reasons for the lower survival among AYA cancer patients is multifactorial, a large part is psychosocial, according to Frediani.

“We’re meeting these patients at very critical junctures in their lives. They’re in the process of graduating high school, starting a career, or starting a family,” she says. “Putting cancer in that environment undoes all of that. It takes them away from school. It takes them away from peer groups. It takes them away from a job, career, their family. The loss of hair and the change the body undergoes-the not feeling well. Dating isn’t quite as ripe.”

That’s one piece of the AYA cancer puzzle. Another is their cancer tends to be different, Frediani says.

“The actual biology of adolescent cancer and young adult cancer seems to be different than our pediatric and adult population. Just simply their age is often a prognostic factor as to whether or not their cancer is treatable. We know that they have a higher burden of side effects compared to the pediatric population. They have AYA-specific side effects that for whatever reason seem to be worse in this particular population,” Frediani says.

Children’s Hospital of Orange County and other cancer centers in the United States, including the Moffit Cancer Center in Tampa, Florida, are focusing on AYA cancer care from different angles, including research. Adolescents and young adults tend to enroll much less frequently in clinical trials, according to Frediani.

Studies also suggest that AYAs treated on pediatric protocols, particularly in diseases such as leukemia, have better outcomes at pediatric versus adult hospitals, Frediani points out.

 That could be in part because pediatric hospitals might have more experience in the more aggressive therapies often used in young patients, she says.

Therapy aside, pediatric and adult oncology hospitals should try to address AYAs’ tremendous psychosocial burden. Programs should focus on the psychosocial well-being of teenagers and young adults during treatment and beyond that includes helping them take ownership of their disease; helping them understand what’s going on; and providing the opportunity to make friends with peers in the hospital, Frediani says.

Adolescent and young adult cancer patients are often withdrawn. “It took me maybe close to a month to get one of my friends from the program interested in going to one of the events,” Meza said. “The first event he attended was the Halloween party. He was kicking himself in the butt for not going after that. I think the security of knowing there are other people who have been through something similar at this hospital, it helped him feel a little more comfortable in his situation.”

The CHOC program focuses on AYA cancer patients aged between 14 and 26 years, according to 

, CHOC child life specialist. The CHOC staff noticed that was the age group that really struggled socially, felt depressed and isolated, and wasn’t engaged in their care. “They weren’t leaving their rooms,” Noskoff said.

Noskoff meets CHOC AYA oncology patients when they’re diagnosed to assess how they’re coping. She helps them navigate their journey through treatment and beyond. “A lot of our patients focus on all the things their doctor tells them they can’t do. I’m focusing on all the things they can do,” she says.

Noskoff will bring in a music therapist if patients like or want to make music. She’ll use the hospital’s onsite studio if patients are interested in graphic design, videography, or photography. For patients who want to continue their studies online, Noskoff can bring in a tutor.

Today, AYA beds at CHOC are mixed in with other age groups. Although the hospital is considering a separate AYA wing, Noskoff says the majority of AYA patients have told her that they like being near the little ones-whether it’s to encourage them through their journey or be encouraged.

“Several of them have said they were in their darkest moments when they were lying in the bed, curled up with the lights off, and someone opens their door, and in that split second they see a 3-year-old riding down the hall on a tricycle with a parent chasing them with the IV pole. In that moment they realize if those children can do it, they can too,” Noskoff says.

It’s important, however, to have AYA-only areas. “That’s a key component to building these programs. Even if you don’t have a whole ward or unit that’s just for young adults, having that space that they can go to be with other people their age is really crucial to building that support group,” Noskoff says.

Programs specifically for AYA patients don’t have to be elaborate, Meza says. “We just set up board games, have pizza or some other kind of food, and just hang out and enjoy each other’s company,” he says.

Other events take more planning, especially if they’re off-site. The CHOC staff and oncology patient leaders have planned prom nights, barbecues to honor patients’ siblings, a holiday party, drumming circles, and much more (Figure 2).

Children’s Hospital of Orange County offers AYA cancer patients education events every other month to address their specific concerns, such as how therapy might affect their sex lives, long-lasting adverse effects, and about survivorship.

“We just did a career resource expo where we brought in people from the community who talked about resumÃ©s and they got to practice interviewing. A few of them walked away with interviews lined up. It was a safe space for them to build that confidence again,” Noskoff says.

The CHOC staff also take about 25 patients and former patients on a yearly retreat to help hone their leadership skills. “One of the big things they told us was they want to give back. That is shown in a couple of ways. One, they want to be at the bedside when these patients are diagnosed. They want to be able to meet the young adults, meet the teenagers, be a friend, be somebody that they can text if they’re having a bad day,” Frediani says.

The CHOC AYA cancer community addresses grieving and loss when one of their friends doesn’t make it through treatment. “We have grief sessions where we get to express our feelings and be close to the people that were close to the person. We can do drum circles, write down our thoughts,” Meza says.

Noskoff says CHOC plans to track the program’s outcomes and quality-of-life measures. The hospital has tracked patient satisfaction, which has improved since the AYA program started. Patient attendance has also grown, multiplying since the program started in 2015. Today’s holiday party attracts roughly 100 patients.

Pediatricians should realize that young adults are not old children and they’re not little adults, according to Frediani. “I think we get into the most trouble when we try to treat them as kids or adults. They’re not really there yet. They don’t have the maturity adulthood brings. They’re also not the carefree 5-year-old,” she says.

Providers shouldn’t be put off when these young adults seem angry, closed off, or unwilling to engage, Noskoff says. “Those are the exact patients that do need us. They’re very protective over their emotions because they don’t want to burden anyone. They’re much more aware of the severity of their illness and the impact that it has. They’re fearful for their lives. They’re grieving the loss of their friends and the life that they had. Getting these patients to participate and be part of this community takes time,” she explains.

Paying attention to the specific needs of AYA cancer patients matters, according to Meza. “The program improves quality of life at the hospital. I’ve seen it firsthand through mentoring patients and experienced it firsthand,” he says.

Frediani, who started working at CHOC about 2 years ago when the AYA program was well underway, says she has no doubt the program helps teenagers and young adults better cope and contributes to better outcomes.

“My hope is in the next 10 years we’ll have the data to prove it,” she says.

1. Hayashi RJ. Adolescent and young adult cancer survivorship: The new frontier for investigation. 

 2. Gupta S, Pole JD, Baxter NN, et al. The effect of adopting pediatric protocols in adolescents and young adults with acute lymphoblastic leukemia in pediatric vs adult centers: An IMPACT Cohort study. 

An innovative program helps adolescents and young adults (AYAs) hospitalized with cancer to cope with their disease and navigate their journey through treatment and beyond.

Children’s hospital addresses AYA patients’ cancer care needs

Pediatricians spend precious time talking with parents whether they’re vaccine hesitant or vaccine opposed.

Yet the time pediatricians spend trying to understand and educate families who are hesitant or against vaccinating their children is important and can be effective, according to Tina Q. Tan, MD, professor of Pediatrics at Northwestern University Feinberg School of Medicine and a Pediatric Infectious Diseases attending at Ann and Robert H. Lurie Children’s Hospital of Chicago, Illinois.

“For the vaccine-hesitant people, the major reason they’re hesitant is either a friend has basically told them vaccines are dangerous, or parents have been reading information on the Internet and they’re just not quite sure what to think,” Tan says.

Even parents who are favorable to vaccination can be confused by the ongoing debate, leading them to question their choices, researchers write in an article published last year in 

“Many parents lack basic knowledge of how vaccines work, as well as access to accurate information explaining the importance of the process,” according to the article.

Often pediatricians can turn around the vaccine-hesitant by educating-not lecturing-parents about their concerns, Tan points out.

Parents who refuse vaccines or refuse the recommended vaccine regimen are far more challenging for pediatricians because these parents are unlikely to budge even after pediatricians talk with them at length about vaccine safety and benefits. Many pediatricians end up dismissing these families from their practices, with good reason, Tan says.

“These children pose a public health risk to other kids that are in the waiting room that are either too young to be immunized or who have medical conditions that prevent them from being immunized,” she says. “I understand it really is a quandary.”

With time, patience, and good communication techniques, however, there is a chance that pediatricians might convince even the most adamant parents that they should have their children vaccinated.

“The one thing you don’t want to do is get mad, even though that’s a natural reaction,” Tan says. “The greatest tip I can give is to find out why the person doesn’t want to vaccinate the child. Listen to them. Be empathetic about their fears and then provide them with accurate information. Talk with them about why vaccines are so important.”

Empathy and respect can lead to trust, and studies show that maintaining trust is important for physicians trying to sway families who might be opposed to vaccinating their children.

Whereas the chances of converting adamantly opposed parents are slim, those individuals make up a small proportion of all parents who are concerned enough about vaccinations to question their value, according to Tan.

Most of the process involves pediatricians’ verbally discussing vaccines with parents, Tan says, but there are free, credible materials that help to back up those talks. 

 offers detailed information about the importance of vaccines for patients. The American Academy of Pediatrics also has handouts for patients and information on its website about the value and safety of vaccines.

1. Hussain A, Ali S, Ahmed M, Hussain S. The anti-vaccination movement: a regression in modern medicine. 

 2. Shen SC, Dubey V. Addressing vaccine hesitancy: clinical guidance for primary care physicians working with parents. 

Pediatricians spend precious time talking with parents whether they’re vaccine hesitant or vaccine opposed. Yet the time pediatricians spend trying to understand and educate families who are hesitant or against vaccinating their children is important and can be effective, according to Tina Q. Tan, MD.