Collaborative Management in Pediatric Atopic Dermatitis - Episode 5
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.
Brittany Craiglow, MD: 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?
Angela J. Lamb, MD: 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.
Brittany Craiglow, MD: 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?
Angela J. Lamb, MD: 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.
Transcript edited for clarity