PracticalDermatology

In an era where physician burnout is at an all-time high—especially among dermatologists—pediatric dermatologist Dr. A. Yasmine Kirkorian’s enthusiasm for the specialty, her job, patients, and colleagues is refreshing. “I feel incredibly lucky to have the best job in the world. Children are loving, sweet, and view the world with joy and optimism. They give me hugs, tell me jokes, and fill me with happiness daily,” says Dr. Kirkorian, Interim Chief of Dermatology at Children’s National Health System in Washington, DC. She spoke to Practical Dermatology® magazine about pediatric dermatology today and her hopes for its future.

What are some of the biggest challenges in pediatric dermatology?

Yasmine Kirkorian, MD: The biggest challenges I face in pediatric dermatology are access for patients to care and caring for patients with complex family circumstances. First, regarding access, pediatric patients disproportionately have Medicaid or other state insurances, which means it can be challenging for them to get access to dermatology in general. Pediatric dermatology is especially difficult because of the scarcity of pediatric dermatologists. Therefore, we serve children who have often waited for a very long time to see us and have severe skin disease that can be challenging to manage. Furthermore, it is difficult to get appropriate medications approved due to insurance issues. Our nurses devote enormous amounts of time to prior authorizations and navigating insurance company requirements to help serve our patients.

Second, children live within a family, and if family circumstances are challenging or unstable, it can be difficult for families to implement treatments. One memorable example was a family in whom we discussed dilute bleach baths for atopic dermatitis. The parent reluctantly revealed after a few visits that the family lived in a shelter with no access to a bathtub. We need to be cognizant of the reality of patients’ lived experiences and how these impact their skin disease.

What have been some of the bigger breakthroughs in treating childhood skin disease in recent years?

Dr. Kirkorian: We are on the cusp of an enormous leap forward in the care of children with skin disease. The FDA has gotten the message that children should be included in clinical trials of new medications. Evidence for this includes the approval of Dupixent down to age 12, which is a major breakthrough for pediatric patients who have severe eczema. I expect that we will see many new drugs approved down to younger ages, which will be critical for getting medications approved by the patient’s insurance companies. A lot of this work is driven by our amazing translational scientists who are studying diseases in children in the laboratory and in clinical trials, which drives discovery for new medications.

What are parents’ biggest concerns and how do you best assuage them?

Dr. Kirkorian: Parental concerns vary based on the disease—whether it’s how to get their child to sleep if they are scratching all night due to eczema or how to deal with the psychosocial stigma of a facial birthmark. All parents want to feel like they are being heard and that you are trying your best to help their child. I try to assuage parent concerns by sitting down and listening during every visit. Sometimes that takes two minutes and sometimes it takes 30 minutes. If you give a parent time to tell their story and express their concerns, you often discover the source of their underlying fear or anxiety. A classic example is a patient with mild pityriasis alba whose parent is in tears. Often this is because they fear their child has vitiligo, which is very stigmatizing, especially in certain parts of the world. In some cases, we cannot solve a problem easily or at all, but if a family feels that you have partnered with them to do everything you can, you generally can form an effective therapeutic relationship to help every child do their best.

Lastly, it is extremely important to connect families and children with chronic diseases such as psoriasis or with genetic syndromes such as ichthyosis with the amazing patient support organizations like the National Psoriasis Foundation or the Foundation for Ichthyosis and Related Skin Types. Additionally, patients have also benefited enormously from Camp Discovery. Their parents benefit, as well, as they see their child thrive and function independently in a group of their peers.

Why is there a scarcity of pediatric dermatologists?

Dr. Kirkorian: The reasons for the scarcity may include lack of exposure to pediatric dermatology in residency, comparably lower salary/income potential in the field, and perception that treating pediatric patients is more challenging than seeing adults. Avenues that have been discussed for improving the pipeline for pediatric dermatology in the past include having a dedicated track for dermatology residents going into pediatric dermatology or accepting pediatrics residents for a post-residency pediatric dermatology fellowship. In the meantime, I feel that it is my mission to train all of our residents to be comfortable taking care of pediatric patients as part of their eventual practice, whether they are general dermatologists or Mohs surgeons or dermatopathologists. After five years of being a pediatric dermatologist, I am proud to say that my former residents often reach out with questions about their pediatric patients. I consider that a great success, because general dermatologists will continue to take care of the majority of pediatric patients in the community.

What are some of the best parts about your job?

Dr. Kirkorian: I cannot emphasize enough how much I love my job. While everyone feels fatigue from long days in clinic, I can truly say that “burnout” is just not something that comes up for me. Taking care of children and working with residents and fellows re-energizes me daily. My clinic is incredibly intellectually satisfying with a daily mix of complex medical dermatology, genetic syndromes, inflammatory diseases, surgeries and lasers. I love the challenge of our inpatient cases where we collaborate with all of the other specialties in the hospital.

I remember wondering in residency why we had to memorize so many seemingly rare diseases, and now I understand because we implement this knowledge daily. Lastly our residents and other rotators are a wonderful source of inspiration as I watch them attain knowledge and mastery of our field. They become my friends and I am thrilled to see their accomplishments as they pursue their dreams.