Pediatric atopic dermatitis treatment landscape

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Raj Chovatiya, MD, PhD: You both alluded to the changing treatment landscape, and now is a great time to talk about some of the treatment considerations for our pediatric patients with atopic dermatitis. It’s something we all like to discuss when we hang out. To get to this point on caregivers, I think we’ve largely pointed out that caregivers play a huge role in terms of preference in choosing treatment, and as Britt has said so eloquently, depending on the stage of life, in many ways, this is going to be a carer driving the plan. At some point, you begin to transition into people having their own personal freedom to make a choice. You really have to feel what the unique situation is in the context of the clinical encounter. The first question, and I’ll throw this one at you, Peter, is when is treatment usually initiated in pediatric patients with atopic dermatitis? What are the triggers, in your practice or in general, for initiating therapy? When do we say we have to do something here.

Peter A. Lio, MD: I really like the concept of the therapeutic ladder. So for the gentlest patients, and frankly, for everyone else, we always want to start with the lowest rung, which is going to be good skincare in general. So, good hydration, gentle cleansing, and avoidance of known triggers. It all goes with education. For some patients we can’t see them, but in the world that might be all they need. It’s awesome. I would rather not medicalize things that don’t need to be medicalized. We are quite busy. I always tell my patients, you’ll never see my face on a billboard, I never advertise, I have all the stuff I need. I don’t want any more patients. I’d rather the patients be better and not need us. This is part 1. Everyone starts there.

If they still have symptoms, especially itching, but sometimes we know pain can be associated with that as well, then I think we need to do something, at least reactive treatment. It’s sort of the next level up on the rung. Historically, we will use topical corticosteroids because they meet the criteria for an excellent first line. They are very accessible, usually inexpensive, most patients can afford them. They are very reliable. Almost every patient who uses them is going to get a good response. There are some that don’t, obviously, but much better than the alternatives. Finally, the fact is that they can be used safely when we use them correctly. So in a reactive setting, we do it for a bit and then take a break. This will bring another large number of atopic dermatitis patients into the mild range.

What if that wasn’t enough? OK, next ring. Then we start thinking about some of the proactive therapies, or maintenance therapies, and one of my favorite articles was from Professor Andreas Wollenberg in Munich, Germany, where he talked about this idea of ​​proactive treatment with tacrolimus the weekend. He was able to show that by having patients put tacrolimus, one of our calcineurin inhibitors and a non-steroidal agent, on hot spots over the weekend he was able to improve quality of life , to reduce the number of relapses and to reduce overall medication. exposure over time. This is largely taken from the notes on how we treat asthma patients. Obviously, if someone continues to have bad flare-ups, we don’t just continue to treat them. Eventually we see that we need talk therapy. This is where I really think our nonsteroidals can shine, and now we’re lucky to have a few different ones. We have tacrolimus, pimecrolimus, we had crisaborole in 2016, then last year we had topical ruxolitinib. So we finally have some really interesting non-steroidal drugs that we can fit into this role. Personally, I always like to use topical steroids as a first line unless there is a reason not to.

What if that wasn’t enough? Well, we’re getting into the bigger guns. We’re starting to talk about systemic therapies, and now we have a lot of options. We have our biologics, we have our JAK inhibitors, and of course we have phototherapy, which is one of my favorite things to do when possible. Then, of course, we have our traditional immunosuppressive drugs that we’ve been using for a long time, as Dr. Craiglow mentioned earlier.

Raj Chovatiya, MD, PhD: Very nice overview. I think we’ll break it down one by one and talk a bit about some of these categories that you mentioned before I talk about some of these non-pharmacological approaches that I think we don’t honestly hear and talk about not close enough because these people may not even reach us in practice.

Transcript edited for clarity

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