Safety vs Efficacy: What AD Treatments Can Be Used in Pediatric Patients?

“For most of our patients, topical steroids remain the mainstay of treatment, but for many of them, particularly when there are some nervous parents, we certainly want to have alternatives that are non-steroidal,” said Amy Paller, MD, in an interview at the Revolutionizing Alopecia Areata, Vitiligo, and Eczema (RAVE) Conference in Chicago, Illinois. Paller, professor and chair of the department of dermatology at Northwestern Feinberg School of Medicine, presented her session “What Can We Use in Our Pediatric Patients?” during the Revolutionizing Atopic Dermatitis portion of RAVE.

With some patient or family concerns regarding topical steroids, Paller is excited to eventually have new, non-steroidal topical treatments for pediatric atopic dermatitis, including tapinarof cream and roflumilast cream. Both therapeutics are currently FDA-approved for the treatment of psoriasis. Paller also hopes to see a decrease in the age of ruxolitinib’s indication to eventually better help pediatric patients with AD.

One key consideration for dermatologists treating pediatric patients with atopic dermatitis is understanding the challenges of certain medications, such as dupilumab. Although dupilumab is efficacious for many and approved for use down to 2 years of age, many patients and their families/parents cannot tolerate administering the treatment as an at-home injection. It’s important to understand the family’s comfort level and provide tips for more pain-free treatments, according to Paller.

New biologics for pediatric atopic dermatitis coming to the market include tralokinumab, approved for patients aged 12 years and older, and lebrikizumab, which should also be approved for adolescent patients.

“Finally, what about the JAK inhibitors? When should we be thinking about them? So far, we have very good safety and of course, they're approved in the United States with abrocitinib and upadacitinib down to 12 years of age. But trials have been ongoing even in younger children, and over time, hopefully, we'll have that oral alternative for our patients,” said Paller.

In her interview, Paller also discussed key differences between treating pediatric and adult patients with atopic dermatitis. For Paller, the first key consideration is safety. For her pediatric patients, Paller always considers the safety of her pediatric patients, especially in the long term. The second key consideration is evaluating if or when pediatric patients with AD can stop their treatments.

“Of course, we're going to have to have a lot more experience to know that, but we're starting to see that with the longest one that's been on the market, dupilumab, that many of our pediatric patients after a year or 2, are doing so well that we're able to just taper. Or even when they stop abruptly, the kids are still doing well. So, we're starting to think a little bit more about the concept of remission,” said Paller.

Lastly, Paller shared her opinions on the 2024 RAVE meeting and the benefit of combining alopecia areata, vitiligo, and atopic dermatitis into one dedicated meeting.

“I would say, with respect to atopic dermatitis, when I did a poll a few years back, 70% of the patients that I see who are pediatric with alopecia areata have a history or have active atopic dermatitis, usually mild, usually not worthy of going on an oral medication or an injectable medication. But nevertheless, we're still thinking about how those 2 diseases are interfacing, and hopefully understanding that more in the future through our use of various systemic medications and further study,” concluded Paller.

Reference

Paller A. What can we use in our pediatric patients. Presented at: 2024 Revolutionizing Alopecia Areata, Vitiligo, and Eczema Conference; June 8-10, 2024; Chicago, IL.