Children and AD

Kohala Coast, HI

- In children with severe atopic dermatitis, dermatologists should feel empowered to match the aggressiveness of their treatment to the aggressiveness of the disease, said Elaine C. Siegfried, M.D., at the Winter Clinical Dermatology Conference.

"Severe eczema is more common than recognized. These children are really therapeutic orphans, but with systemic therapies, they can be helped," said Dr. Siegfried, professor of pediatrics and dermatology, Saint Louis University, St. Louis, MO.

While there are multiple options to choose from among available systemic immunomodulators, Dr. Siegfried said she now considers methotrexate as her first-line agent. The advantages of this drug include its long-term track record - methotrexate has been used for decades in thousands of children. In addition, it is inexpensive and has a convenient once-a-week dosing regimen.

Although there are potentially serious side effects of methotrexate - the labeling includes 12 black box warnings - the risks are associated primarily with the use of high doses, such as those used for cancer chemotherapy.

"Any drug that has been given intrathecally to children who have been shown to do well over long-term follow-up confers a degree of confidence about its safety. In fact, for the treatment of children with atopic dermatitis, I have found a low dose of methotrexate is very well-tolerated," said Dr. Siegfried.

Dosing is initiated with 0.5 mg/kg/week, usually administered as a single oral dose but sometimes divided, and folic acid is administered every other day on non-methotrexate days. Monitoring involves laboratory studies (CBC, liver function tests and homocysteine) at baseline, monthly for 3 months and then quarterly. Some children get elevated transaminase levels, but that is not a cause for alarm, Dr. Siegfried said.

"I have kept many children on their medication and the transaminase level decreased despite continued treatment. However, I may reduce the dose or stop the methotrexate temporarily in patients with relatively higher transaminase levels," she noted.

Liver biopsies are not ordered in children, she said, as methotrexate-associated liver disease occurs primarily in people with other risk factors.

Before starting potentially toxic medications, patients with severe, refractory atopic dermatitis may be hospitalized for intensive skin care to "put out the fire". This setting also provides an opportunity for extensive teaching of the child’s family, Dr. Siegfried said.

Based on some emerging evidence that vitamin D deficiency is a risk factor for atopic dermatitis, Dr. Siegfried said she is beginning to check serum vitamin D levels in her patients and recommending supplementation with oral cholecalciferol as needed. DT