What's new for atopic dermatitis in children

Vikash S. Oza, MD, and Matthew J. Zirwas, MD, discuss the current Rx and Dx of atopic dermatitis in children at the virtual Maui Derm MP+PA Fall 2021 conference.

Can we prevent atopic dermatitis in children going forward? When should you question your diagnosis? What is in the pediatric pipeline for this condition? These were some of the questions posed by Vikash S. Oza, MD, associate professor, Dermatology and Pediatrics, Ronald O. Perelman Department of Dermatology, NYU Grossman School of Medicine in New York City, at the virtual Maui Derm NP+PA Fall 2021 conference.

Oza started his presentation with a reminder that AD is a prevalent childhood condition, with the largest incidence showing in children 3-5 months of age (14%-25%), followed by 5-18 years (11%). “It has a quality of life impact and symptoms may not be stable over time,” Oza noted. The impact of prevention goes far beyond AD itself, as oral exposure can affect the gastrointestinal (GI) tract, while cutaneous exposure can impact Th2 memory cells.

In terms of prevention, studies have been done, noted Oza, that show how emollient enhancement of the skin barrier from birth can be an effective AD and eczema deterrent. In terms of other prevention, Oza pointed to bathing frequency associative to AD, with infants at 3 months old (with no known predilection for AD) who bathed daily having a 60% greater chance of getting AD than those who bathed once a week.

Other preventive measures included checking water quality (hard water had a strong correlation with AD), breast feeding (exclusive breast feeding in the first 4 months reduced AD prior to 2 years), prenatal and postnatal probiotic use.

When questioning diagnosis, Oza said, “AD red flags include early infancy erythroderma, poor response to topical corticosteroids, atypical distributions, and multiple, early in life infections.”

Looking at the pediatric pipeline for the treatment of AD, Oza pointed to topical medications in phase 3 clinical trials, including ruxolitinib and delgocitinib, and systemic therapeutics including dupilumab and abrocitinib. (dupilumab was approved in May 2020 for children ages 6 and older).

Next, Matthew J. Zirwas, MD, ACDS, Contact Allergen Management Program (CAMP) and founding director, North American Contact Dermatitis Group, looked at the current and new medications that can treat AD, as well as why some therapeutics have been delayed in coming to market. Zirwas noted, “My belief is that the FDA is delaying a decision on approving JAK inhibitors for AD while they have been analyzing the results of the long term trials of tofacitinib. We truly do not know how much JAK specificity matters, nor do we know if there are substantial safety differences when used for different disease states.”

Zirwas then reported the latest dupilumab updates, which show that the drug protects against skin infection by increasing peptide production and decreasing Staph colonization, reducing skin infection by 40%. Finally, Zirwas gave his list of recommendations for therapeutics to treat AD, including prescribing dupilumab (if a patient has asthma or significant allergies); abrocitinib, upadacitinib or baricitinib (for rheumatoid arthritis), and abrocitinib or upadacitinib (for the strongest and fastest treatment of AD).

Reference

Oza VS, Zirwas M. Atopic dermatitis update. Presented at Maui Derm NP+PA Fall 2021; September 30 to October 2, 2021; live in Asheville, North Carolina, and virtual.