PracticalDermatology

Latanya Benjamin, MD, a pediatric dermatologist and owner of Young Skin MD in Coral Springs, Florida, is on the front lines of treating atopic dermatitis (AD) in children. For years, there wasn’t all that much she had to offer kids with moderate-to-severe disease, but fortunately, that has changed with the availability of a new crop of systemic treatments–and even more to come.

Dr. Benjamin talks to Practical Dermatology about today’s treatments and our growing understanding of the pathogenesis of itch in AD, plus more.

What is new and exciting for treating AD in kids?

Latanya Benjamin, MD: We have long been awaiting the Janus kinases (JAKs) inhibitors, and now we have three approved for both adult and pediatric populations. We have Cibinqo (abrocitinib), Rinvoq (upadacitinib), and Opzelura (ruxolitinib 1.5% cream) for adults and adolescents aged 12+ years with moderate-to-severe AD.

Now that there are more options to treat AD, how do you choose?

Dr. Benjamin: It depends on the patient’s age. We have excellent data on Dupixent (dupilumab) in younger patients. This drug has the youngest age indication. It is approved for children aged 6 months and up with moderate-to-severe AD, so it is typically my go-to in my youngest patients.

What causes AD?

Dr. Benjamin: Epidermal barrier dysfunction is a significant contributor to the development of AD in the majority of patients. Other patients can be affected due to irregularities of their immune system and genetics. Even these patients, for the most part, share this specific barrier dysfunction. That being said, the key organ here is the skin. As we learn more about the microbiome in the prevention and treatment of AD, we are learning that the skin microbiome engages in a lot of crosstalk with other organs including the gut and brain. Bacteria on the skin play a role in AD flares and can even produce keratinocyte-derived cytokines, such as thymic stromal lymphopoietin (TSLP). We are still elucidating the key roles that microbiomes play in this disease state.

What is new in our understanding of itch in AD?

Dr. Benjamin: There has been more delineation of key cytokines that are important in AD, in general, and in itch, in particular. Some well-known cytokines such as interleukin (IL) IL-13 and IL4 are T helper type 2 (Th2)-derived. We are gaining a greater understanding about keratinocyte-derived cytokines and chemokines such as TSLP, IL-33, and IL-31, that may modulate itch. These discoveries are leading us toward new therapeutic targets. The therapies that are going to target itch are pretty exciting. Lebrikizumab, for example, is an injectable monoclonal antibody that targets IL-13 and may be effective for itch pruritus reduction. Nemolizumab, an IL-31 receptor A agonist, may also help mitigate pruritus.

What does multidisciplinary care look like for kids with AD?

Dr. Benjamin: Many of these newer therapies and biologic agents are US Food and Drug-approved for multiple indications, such as treating asthma and other Type 2 mediated disease states in addition to atopic dermatitis. As a result, I am collaborating and co-managing patients with other specialists who are prescribing these medications in these areas. I am also helping teach primary care physicians how to best navigate vaccine schedules and other prescribing matters when children are placed on these medications

How do you diagnose/treat eczema in darker skin types?

Dr. Benjamin: It is harder to detect erythema in darker skin, so I have a lower threshold for treating patients with darker skin tones who present with itch. I am careful not to undertreat just because I can’t see the classic phenotype of redness. There is a subset of patients who delay seeking and thus receiving care. By the time we see them, they have pronounced lichenification with extra thickened skin from chronic rubbing, scratching, and itch so it is really important to treat these patients judiciously.

How does AD affect the quality of life for the patient and their families?

Dr. Benjamin: It is high up there among other serious chronic conditions. Itch impacts sleep and that negatively affects the entire family, including siblings at home. We see sleep-deprived parents because they are trying to soothe their child’s itch or because their child has scratched throughout the night to the point of bleeding. They are exhausted. We can help.