The advent of powerful new biologic medications such as dupilumab is starting to change the way that dermatologists treat moderate to severe eczema, but most of the benefits haven’t trickled down to the pediatric population…yet. Vikash Oza, MD, Director of Pediatric Dermatology at NYU Langone Health in New York City, discusses some of the challenges and opportunities that this shift presents for children.
What is the most significant unmet need in pediatric dermatology today?
Vikash Oza, MD: There is a large burden of skin disease in children and many times we still rely on older medications. We are learning so much about atopic dermatitis (AD), and advances in understanding the pathophysiology have translated into newer generations of medications like dupilumab and numerous other biologics and topicals in the pipeline.
Whenever there is rollout of a new medication, there is always a delay in getting the medication to the pediatric population, due to questions of dosing and safety. We need more clinical studies on the safety and efficacy of the newer generation agents in children and more comparative research looking at newer medications against standard of care, so we have a better understanding of how to utilize these drugs in clinical practice.
Pediatric dermatologists need to understand who to put on this newer generation of medications and when. Despite the exciting development of new medications, the fundamental issues in atopic dermatitis of patient education and compliance still remains. There is a lot of room to build educational tools and develop consensus guidelines, such as what defines failure of topical therapies.
Can effective AD treatment stop the atopic march?
Dr. Oza: We don’t have enough evidence yet to tell us that this is true. There is exciting research on the potential of using daily emollients shortly after birth to prevent the development of atopic dermatitis at six months of age, and one could hypothesize that this could modulate the risk of other atopic conditions, such as food allergies, seasonal allergies, and asthma. We are still some time away from using systemic biologics in infants to modulate risks.
How does AD affect quality of life?
Dr. Oza: The defining symptom of atopic dermatitis is itch. Chronic itch often leads to disrupted sleep. Affected patients wake in the middle of night due to itch, and poor sleep has numerous consequences, including higher risk of attention deficit hyperactivity disorder and learning or other behavioral issues in school. Caring for a child in distress with atopic dermatitis also takes its toll on the family. Furthermore, the interventions that we ask families to perform, such ointments, baths, and prophylactic moisturization, can be time-consuming and overwhelming.
What are some of the barriers to adherence in this population?
Dr. Oza: The main obstacle for adherence in younger children is “steroid phobia.” Most families are scared of topical steroids, even though these have been the first-line treatment for atopic dermatitis for decades. It is important to address steroid phobia with every family when prescribing topical treatments.