Pediatric Pearls From the Literature: Highlights From 2023 and 2024

Sheila Fallon Friedlander, MD

For advanced practice providers and clinicians, keeping up with the dermatology literature can feel like a full-time job. But it’s necessary to stay up-to-date on the latest research and treatments in order to provide the best care to patients.

At Maui Derm NP+PA Fall 2024 conference, held September 15-18, 2024, in Nashville, Tennessee, a trio of board-certified dermatologists presented a session recapping the top takeaways from dermatology literature published in 2023 and 2024.1 Sheila Fallon Friedlander, MD, of the Scripps Clinic in San Diego, California, focused on updates relevant to the pediatric patient population, including things to keep in mind or watch out for when dealing with complicated cases.

First, is cutaneous Crohn’s disease, which is characterized by granulomatous changes. Of 89 patients with cutaneous Crohn’s who were included in a case series published in Pediatric Dermatology,2 55% were male and 82% presented with edema. Of this group, interestingly, 22% did not have any gastrointestinal involvement. The most frequently affected site was the genitals, where erythema, edema, knife cut lacerations, and fissuring are often observed, as well as the lower extremities and the face, where nodules, plaques, ulcers, fissures, lichenoid, and perifollicular papules can present. Treatment is typically dual biologic therapy and oral steroids, but recognition is the first line of defense.

“That's something where we, [and] now you all, may recognize this,” Fallon Friedlander said during her presentation. “The pediatricians are not going to recognize, [and] the generalists probably won't, but hopefully you will.”

Fallon Friedlander turned next to the concept of the atopic march and what efforts exist to halt the natural course of chronic disease. Typically, with the atopic march, children present first with eczema and go on to develop things like asthma, hay fever, food allergies, and other diagnoses that end of being more of an issue than the initial eczema. Is it possible, Fallon Friedlander posited, to disrupt the inflammatory cascade that occurs when antigens infiltrate a leaky skin barrier? According to a large population-based cohort study with more than 2000 patients in each arm,3 the 3-year incidence of atopic march progression was lower in the dupilumab group than among those on conventional immunomodulators (majority topical).

“When you have a kid with significant eczema and you're thinking about dupilumab, families are scared. They don't want to put their child on something that gets injected,” Fallon Friedlander said. “But if you have a conversation explaining the possibility of perhaps changing other problems that could develop in them, the family is going to look at it a little differently.”

Another aim for clinicians is to prevent unwanted or dangerous side effects in patients. When it comes to acne, the favorite oral drug of choice is typically a tetracycline antibiotic such as minocycline or doxycycline, according to Fallon Friedlander. However, there is some concern for the development of idiopathic intracranial hypertension, or pseudotumor cerebri. A population-based cohort study4 of more than 200,000 patients found no increased risk of pseudotumor with doxycycline compared with minocycline (hazard ratio 1.78 compared with 2.69), bolstering the argument for using doxycycline as first-line treatment.

Advanced practice providers need to understand pathways in order to better understand the genetic basis for a lot of diseases, Fallon Friedlander said. This will enable providers to better target therapies based on molecular analysis. A great example of this is the topical herpes simplex virus-based gene therapy beremagene geperpavec (B-VEC), which was approved in May 2023 for the treatment of dystrophic epidermolysis bullosa (DBE). Data from a randomized double-blind controlled trial5 of 31 patients showed complete wound closure at 6 months in 67% of patients compared with 22% placebo.

There is also some evidence for the use of birch bark extract for epidermolysis bullosa. Data from a phase 3 study of Oleogel (birch triterpenes) showed that 41% of actively treated wounds achieved complete closure within 45 days (P = .013) compared with 29% placebo.6The treatment, which is already approved in the UK and EU, comprises 10% birch bark extract and 90% sunflower oil. Adverse events were similar across the study and placebo arms.

Lastly, Fallon Friedlander discussed molluscum contagiosum, a signature pediatric condition characterized by small, raised lesions with dimples in the middle. She called out the recently approved “game-changer” berdazimer gel, which is an at-home treatment that patients can apply themselves.7 However, it is still not yet available. What is available is VP-102, a drug-device combination that contains a formulation of cantharidin 0.7% that includes a surgical dye meant to clearly mark treated lesions.

In closing, Fallon Friedlander reiterated that dermatologists, dermatology nurse practitioners, and physician assistants are sometimes the first to identify systemic disease, like in the case of cutaneous Crohn’s disease. There are also now options for serious disease, like DBE, and more tools in the toolbox for common ailments, such as molluscum.

References:

1. Rosen T, Fallon Friedlander S, Zirwas M. Literature from 2023 & 2024 in review. Presented at: Maui Derm NP+PA Fall; September 15-18, 2024; Nashville, Tennessee.
2. McKay G, Liu L, Shaw K, et al. Pediatric cutaneous Crohn disease: A case series of 89 patients and review. Pediatr Dermatol. 2024 Jul 16. doi: 10.1111/pde.15689. Online ahead of print. Accessed September 15, 2024. https://pubmed.ncbi.nlm.nih.gov/39011834/
3. Lin TL, Fan YH, Fan KS, Juan CK, Chen YJ, Wu CY. Reduced atopic march risk in pediatric atopic dermatitis patients prescribed dupilumab versus conventional immunomodulatory therapy: A population-based cohort study. J Am Acad Dermatol. 2024 Sep;91(3):466-473. doi: 10.1016/j.jaad.2024.05.029. Epub 2024 Jun 14. Accessed September 15, 2024. https://pubmed.ncbi.nlm.nih.gov/38878041/
4. Thang CJ, Garate D, O'Leary S, Golovko G, Wilkerson MG, Barbieri JS. Evaluation of the association between tetracycline-class antibiotic use in patients with acne and idiopathic intracranial hypertension risk: a population-level cohort study. Br J Dermatol. 2024 May 17;190(6):921-923. doi: 10.1093/bjd/ljae099. Accessed September 15, 2024. https://pubmed.ncbi.nlm.nih.gov/38530996/
5. Guide S, Gonzalez M, Bagci IS, et al. Trial of beremagene geperpavec (B-VEC) for dystrophic epidermolysis bullosa. N Engl J Med. 2022 Dec 15;387(24):2211-2219. doi: 10.1056/NEJMoa2206663. Accessed September 15, 2024. https://pubmed.ncbi.nlm.nih.gov/36516090/
6. Kern JS, Sprecher E, Fernandez MF, et al. Efficacy and safety of Oleogel-S10 (birch triterpenes) for epidermolysis bullosa: results from the phase III randomized double-blind phase of the EASE study. Br J Dermatol. 2023 Jan 23;188(1):12-21. doi: 10.1093/bjd/ljac001. Accessed September 15, 2024. https://pubmed.ncbi.nlm.nih.gov/36689495/
7. Browning JC, Enloe C, Cartwright M, et al. Efficacy and safety of topical nitric oxide−releasing berdazimer gel in patients with molluscum contagiosum. JAMA Dermatol. 2022;158(8):871-878. doi:10.1001/jamadermatol.2022.2721. Accessed September 15, 2024. https://jamanetwork.com/journals/jamadermatology/fullarticle/2794188