Q&A: Biologic Therapies in Pediatric Dermatology - Vaccines, Adverse Effects, and Personalized Care

At the recent 2024 Society for Pediatric Dermatology Annual Meeting in Toronto, Canada, Michele Ramien, MD, spoke at a session called, "Challenges in Biologic Therapy: Vaccinations, Complications, and Treatment Nuances," alongside fellow clinicians Stephen Humphrey, MD, Medical College of Wisconsin; and Elaine Siegfried, MD, St. Louis University SOM/Cardinal Glennon Children’s Medical Center.

Ramien is a pediatric dermatologist and dermatologist at the Alberta Children's Hospital in Calgary, Canada, and has interest in severe cutaneous reactions, also doing research in atopic dermatitis.

Following the conference, Ramien spoke with Dermatology Times to discuss highlights from the group's session and pearls for biologic and advanced therapy in pediatric dermatology.

Q&A

Q: Can you provide a brief overview of your presentation on biologic therapy?

A: I was honored to be invited to give a presentation with 2 colleagues at the Society for Pediatric Dermatology meeting in Toronto in July about biologic therapy and targeted therapy, in particular. We split the presentation into 3 parts. There was a discussion of vaccinations. We talked about adverse events in particular, and then the discussion evolved into: What is the long term look like for these patients who are on targeted therapies or biologics? Is there a role for tapering therapy over time? How do we adjust therapy to optimize outcomes, and what does that look like in these really young patients who are starting an advanced therapy?

Q: How do biologic therapies impact the effectiveness and safety of vaccines?

A: It probably depends a lot on the targeted therapy or the biologic that is being used. We know with some of the older biologics, the biologics that have been approved for longer, for example, for psoriasis, we have anti-TNF agents, and then there are the more targeted cytokine inhibitors. You know that the more upstream in the immune system that the biologic is targeted at, or that the targeted inhibitor targets, the more chance there is that there would be an impact on number 1.) vaccine efficacy, but number 2.) potentially a risk of having a vaccine strain infection. I think the vaccine strain infection risk is really mostly theoretical; it isn't something that can be studied in a very controlled setting, so there's no way to know that the risk is zero. We are cautious with some of those less targeted therapy, such as, for example, the anti-TNFs, the biologics, but also targeted therapies like JAK inhibitors that would affect more of the immune response to infections, and then the idea that it might affect vaccine responses.

When we give a vaccine, how good is the protection going to be afterward? That part is poorly studied, so I think the idea still is that we would only give, and it's particularly for the live attenuated vaccines that this risk exists of potential vaccine strain infections. In terms of vaccine responses, we know that for many of the therapies that have been around for longer, that vaccine responses are okay. It's more with the newer therapies, there are probably more questions, and we just need better data. I think in kids is the bottom line where we are extrapolating from adults, and so I think we are reasonably cautious, maybe too cautious. The data just doesn't exist yet for children.

Q: How do you approach the management of adverse effects related to biologic treatments in your practice?

A: Being familiar with the biologics that we're prescribing is probably the first step, so having a good idea what the potential side effects are, and the reality is now, and we heard about this a lot at the SPD, too, is that all the information is out there, so families that are using the internet, using social media, using different resources, patients are getting the information. The part that we can help with, as providers who are experienced, is to curate the information that patients are be are able to collect, because our experience can inform decision-making or using that information to help contextualize it for the patient. There is a lot of information out there, and it's hard to digest and understand how it relates to your child.

I think that knowing our medications well, understanding our patient, our individual patients' past medical history, their clinical situation, what their goals of care are, that enables us to have a good discussion about adverse potential risks of therapy, and at the end, and when it comes down to it, the risks are pretty are relatively low, but they're not zero. Then, when we're talking about a child who's starting a therapy at a very young age, it is a different discussion, because we don't know how long they're going to be on the therapy, and the tolerance, or the risk tolerance, is probably a little bit lower than for an adult.

Q: How do you tailor biologic therapy to meet the specific needs of different patients?

A: It's really shared decision-making. Now, the exciting thing is that this is a problem that we do have, because in the past, we didn't have options to treat patients with advanced therapies, but now we have many different options. If we take a disease like atopic dermatitis, in the past, we had topicals, and then some of the traditional immunosuppressive therapies, and maybe short courses of prednisone, which are obviously not recommended, but were used in rescue situations. Now we have targeted therapies. We have JAK inhibitors, we have biologics for atopic dermatitis. It becomes a discussion about the patients, the severity of their disease, what they're looking for in terms of improvement, and the timeline that they're looking for. Some patients may have some kind of important event that's coming up very soon, which would require a different approach to therapy than someone who is not as bothered by their disease, but might have different comorbidities. That's a big part of the discussion, too, is thinking about how we can choose therapies that might manage multiple diseases at once, because we have good evidence that some of our more advanced therapies can do that, too.

Then in children, the other big consideration is method of administration, because not every child will accept having an injection. That kind of shifts the discussion as well, a little bit. But I think the nice part is that we have options to present, and understanding what the patient and the family's goals are can help us to suggest a few options and then help the family and patient to choose the right option for them.

Q: What advice would you give to dermatologists who are new to or hesitant to prescribing biologic therapies?

A: I don't know if I can understand everyone's past experience, so I'll give a suggestion that will fit for everyone. For me, what I can say, what I do, is that when I look at a patient and I try to understand their disease after meeting them in consultation and taking their history and examining them, what I try to understand is what the impact of this disease is on their life, on their quality of life, on their family's life. The kind of tricky part is to sort out if this is a patient who even knows what it is like to live a normal life, because I think a lot of times, people under-report how severe their disease is. But you can get an idea from the history. You can get an idea about that from the history as well.

Then understanding that as dermatologists, we are the experts in these therapies. We have really experienced colleagues and our rheumatologist and gastroenterologist colleagues, some of the hematologists, who've been using these medications for longer than we have. We understand the disease mechanisms, and we understand the disease burden. We are the best positioned to offer these therapies to people, to patients, to families, who have been really impacted by pediatric skin disease. I think it's our responsibility to consider giving these therapies for patients where the benefits of the therapy might outweigh the potential concerns. I think as we have more and more data available about the safety of targeted therapies and biologics, the comfort level of prescribers will also increase, because when you see the benefits of these therapies, and these children who, before, we had no options for them, and they were just waiting to grow out of their skin disease: We don't have to do that anymore. We can help them to live a normal life, to reach their full potential, to give their family back their full potential right now. That's kind of what I think about when I'm assessing a patient and thinking, "Do I really want to propose the targeted therapy where there might be some risks?" I think the risks of leaving the disease untreated are also significant and sometimes under recognized.

Q: Is there anything else we did not discuss that you feel is important for fellow dermatology clinicians to know?

A: There's 2 things that I thought were really interesting that came up in the discussion. One part was about long-term adjustment of therapy, and that was Elaine Siegfried's session. I would refer people to some of her recent publications, or even to the recordings from the meeting to see hers, because she speaks very articulately on this topic. But what my take home message from what she discussed was really that there are patients who don't need full-dosed therapy in the long term. There are some patients, and we don't know if it's disease modification, that we're changing the course of the disease, or that these are patients who would have naturally gone into a remission, and now they just don't need as much of our treatments anymore.

I think one of the things that really hit home for me, and something that I've been trying in my practice as well, is that when I have someone who's really controlled for, let's say, 6 months to a year on their therapy, we try to pull the therapy back a little bit, and whether that is a dose reduction or increasing the interval between if it's a biologic injections, or reducing the interval between dosing to, for example, every other day for an orally-administered targeted therapy, then those might be options. That might also reduce the toxicity and the cost long-term of these advanced therapies, too.

Then the other thing that I think is worth mentioning is that we had thought it would come up [in the session], and we didn't get any questions on it. It was about administration of biologics in children, that it can be really challenging. This is something that as dermatologists, we haven't really had to think about before. We haven't had to give biologics, other than in very rare instances, and usually to very, very sick patients. We haven't had to regularly give biologic, injected therapies to young children, but we have colleagues in other specialties who have more experience giving injections. I think having a process and an approach to injections and frequent injections in young children is really critical, and it is a part of the success of the therapy, because if every injection is stressful, then it's not going to be a good long-term option. But there are ways that we can do better and make these therapies available for more children who have really severe disease.