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Allergic contact dermatitis and atopic dermatitis are common causes of rashes in the pediatric population. Patch testing can help demystify the cause of such skin conditions and determine treatment.
Most children will break out in/develop a rash at some point, but commonness does not make these skin conditions any less irritating or, in some cases, painful. Rashes are often caused by eczema or allergic contact dermatitis, which while similar, can be treated differently and recognizing the differences and causes is essential to making a correct diagnosis—the key to proper treatment and, ultimately, relief, according to JiaDe Yu, MD, FAAD.
Yu, director of the Contact Dermatitis and Occupational Dermatology Clinic and an assistant professor of adult and pediatric dermatology at Massachusetts General Hospital in Boston, detailed the fundamentals and latest approaches for both skin disorders in a presentation on pediatric AD at the 2022 American Academy of Dermatology Annual Meeting in Boston.1
Knowing the Nuances
Eczema is frequently characterized by intense itching, which can damage skin and worsen the rash. AD is the most common form and typically presents early in life, with most patients developing the condition before their fifth birthday. Eczema can appear differently on skin of color—an important point because Black and Asian American children develop AD more often than their White counterparts, and Black children potentially have itchier, more severe eczema.2
Eczema may resolve as a child grows up, but 50% of patients still will have it when they reach adulthood. Although there is no way to know if the condition will persist, early diagnosis and treatment can prevent severe disease, which can be harder to treat and is more likely to continue into adulthood.
Although it can be confused with eczema, allergic contact dermatitis can generate symptoms such as rash, tenderness, burning, and blisters. Metals such as nickel and cobalt, which can be found in toys, clothing accents, and costume jewelry, are likely allergens among children. Soaps, shampoos, and laundry detergents are sources of 2 other common allergens: fragrance and preservatives. Chemicals and dyes used to treat fabrics can also induce a reaction.
“Dermatologists are seeing 2 emerging allergens affecting children—adhesive allergens, which are commonly used in wearable blood glucose monitors, and acetophenone azine, linked to reactions associated with…an allergen from a chemical used in shin guards and footwear,” Yu noted.3
Knowing a rash’s location and getting a thorough family history of skin conditions can help differentiate the conditions. Allergic contact dermatitis often arises in unusual locations—say, fingertips, eyelids, or lips—whereas eczema frequently presents on areas such as the wrist or back of knee. Because allergic contact dermatitis worsens eczema, children who have eczema should avoid common allergens when possible.
Patch Testing for Allergens
Yu suggested referring patients to a specialist for patch testing because it can reveal allergic contact dermatitis. “Patch testing is the gold standard for detection of allergic contact dermatitis in adults and children,” he said. “It is the belief of contact dermatitis experts that patients should be patch tested before starting a systemic immunosuppressive agent such as methotrexate, cyclosporine, [or] dupilumab [Dupixent; Sanofi and Regeneron Pharmaceuticals]…due to the potential for ‘curing’ their dermatitis with allergen avoidance alone.”
Approximately 40% of pediatric patients with AD have a relevant positive allergen that may contribute to their dermatitis, Yu continued. Lack of awareness of the potential allergen can lead to unnecessary long-term treatment with topical steroids or systemic immunosuppressants.
Choosing Among Treatments
Dermatologists have a wide range of choices for treatment. Although dupilumab has shown efficacy for AD in the pediatric population, Yu said, some patients fail treatment. In these cases, options include tralokinumab (Adbry; LEO Pharma)—the agent specifically binds to and inhibits the cytokine IL-13—and Janus kinase (JAK) inhibitors such as abrocitinib (Cibinqo; Pfizer) and upadacitinib (Rinvoq; AbbVie). Upadacitinib is FDA approved for patients 12 years and older with moderate to severe AD, whereas abrocitinib is approved only for adults.4,5
According to Yu, tralokinumab has an adverse event (AE) profile similar to that of dupilumab, but JAK inhibitors are still being explored.
“In children, we always try to be more cautious, and therefore most pediatric dermatologists would likely offer safer treatment options like dupilumab or tralokinumab prior to novel JAK inhibitors until more is known about the [AE] profiles in children with atopic dermatitis,” Yu said.
The drugs’ ease of dosing and delivery is an important discussion point with patients. If a therapy requires multiple doses a day, adherence may be difficult; if it causes pain, the patient may be resistant. “In my experience, once children see the significant benefit a particular medication has on their skin, they are more likely to adhere to the dosing regimen,” Yu said.
Considering Alternative Options
In addition to allopathic medicine, which is a system in which physicians and other healthcare professionals treat symptoms and diseases using drugs, radiation, or surgery, alternative regimens may benefit pediatric patients with eczema, according to Yu. Integrative approaches to consider, in his view, include acupuncture, behavioral therapy, and relaxation techniques, which may help reduce stress, a factor that worsens eczema and AD. For at-home help, apps such as Calm can Headspace offer breathing exercises, but these may not be as suitable for younger patients.
“Natural therapies such as sunflower oil, extra virgin coconut oil, and safflower oil have the most evidence for being effective,” Yu said. “However, I make sure to avoid products for which I don’t know the ingredients, given risk for contact dermatitis.”
1. What’s causing your child’s itchy rash? American Academy of Dermatology. March 25, 2022. Accessed March 26, 2022. https://www.aad.org/news/cause-childrens-itchy-rash
2. Kaufman B, Alexis A. Eczema in skin of color: what you need to know. National Eczema Association. February 16, 2018. Updated July 15, 2022. https://nationaleczema.org/eczema-in-skin-of-color/
3. Reeder M, Atwater AR. Acetophenone azine: The 2021 American Contact Dermatitis Society allergen of the year. Cutis. 2021;107(5):238-240. doi:10.12788/cutis.0252.
4. U.S. FDA approves Rinvoq (upadacitinib) to treat adults and children 12 years and older with refractory, moderate to severe atopic dermatitis. AbbVie. Press Release. Published January 14, 2022. Accessed January 17, 2022. https://news.abbvie.com/news/press-releases/us-fda-approves-rinvoq-upadacitinib-to-treat-adults-and-children-12-years-and-older-with-refractory-moderate-to-severe-atopic-dermatitis.htm?view_id=6943
5. Breaking news: FDA approves Cibinqo (Abrocitinib). National Eczema Association. Published January 14, 2022. Accessed January 17, 2022. https://nationaleczema.org/cibinqo-approval/