Understanding and Treating Pediatric AD Inside and Out

In a recent Dermatology Times DermView custom video series, “Updates in Pediatric Atopic Dermatitis,” Lisa Swanson, MD; and Lawrence Eichenfield, MD, discussed the complexities of pediatric atopic dermatitis (AD) and the potential of innovative therapies.

Swanson, a dermatologist and pediatric dermatologist at Ada West Dermatology and St Luke’s Children’s Hospital in Boise, Idaho, and Eichenfield, a clinical professor and vice-chair at the University of California San Diego, and pediatric dermatologist at Rady Children’s Hospital-San Diego, shared the latest insights into AD pathophysiology, the challenges of misinformation and disease burden, and the exciting advancements in topical and systemic care.

Dermatology Times DermView custom video series, “Updates in Pediatric Atopic Dermatitis”

The Complex Pathophysiology of Pediatric AD

The session began with an overview of the pathophysiology of AD, focusing on type 2 inflammation, which plays a central role in the disease. AD often arises from a combination of genetic predisposition, which leads to dry skin, and environmental triggers that exacerbate inflammation. Type 2 cytokines such as IL-4, IL-13, and IL-31 are implicated in driving this inflammatory response, affecting both the skin barrier and immune system. The interaction between these factors creates a vicious cycle of inflammation and skin barrier dysfunction, which worsens itching and rash.

“For so long, people debated, ‘Is AD outside in or inside out? Is it the barrier? Is it the immune system?’ And I think we’ve learned it’s both, and they’re playing off... one another. If you injure one, you’re going to have an effect on the other,” Swanson noted.

Both doctors emphasized the complexity of AD, noting that it involves genetic and environmental factors and often leads to conditions such as asthma and allergies. Pediatric patients with AD are at higher risk for developing these inflammatory conditions, and these comorbidities must be mentioned during visits, even with the time constraints of short appointments. Although food allergies may contribute to AD in some cases, they are rarely the sole cause, but it can be beneficial to collaborate with local allergists to provide comprehensive care.

Understanding Disease Burden and Challenges

Eichenfield and Swanson also addressed the significant burden the condition places on patients and their caregivers. They stressed the importance of assessing the impact of AD on a child’s quality of life, including their sleep, activities, and overall emotional well-being. Eichenfield described how, in more severe cases, he takes time to explore the broader effects of the disease on the family, noting that families often adapt to ongoing issues without fully recognizing the extent of the burden until treatment begins. Swanson also shared a strategy of asking patients and their families, “Is there anything you’re not doing because of your atopic dermatitis?” which helps highlight the disease’s far-reaching impact.

The conversation also touched on the challenges of educating families about treatment options, particularly in the context of misinformation circulating online and on social media. Both clinicians recognize a growing fear of topical steroids due to myths about steroid addiction and withdrawal, even though such issues are rare in pediatric patients.

“I think we haven’t done a good job of mediating social media knowledge of AD, its course, and its impact,” Eichenfield noted. “We’re in such a positive state in terms of our ability to mediate disease, but we have probably more fear than we’ve had before among patients and families.”

Both doctors emphasized the need for dermatologists to carefully navigate these misconceptions and provide reassuring guidance with realistic expectations to help families make informed decisions.

A Growing Arsenal of Modern Treatment Options

The discussion ended with an exciting analysis of the expanding landscape of AD treatments, focusing on new topical nonsteroidal and systemic therapies.

“I tend to do analogies [in my office],” Eichenfield shared. “Now I have this set of hammers, and screwdrivers, and pliers...core tools that can be highly useful in practice, and I think we’re at the incredibly cool part of them being handed to us.”

Eichenfield and Swanson covered the latest nonsteroidal, topical agents and emphasized their efficacy, safety profiles, and unique characteristics. They praised ruxolitinib, approved for patients aged 12 and older, for its steroid-like efficacy, speed, and tolerability that impresses patients and their families.

“It’s become my favorite for patients on the spectrum who have some tactile sensitivities because it really doesn’t sting and burn at all, which is very impressive in our eczema population,” Swanson said.

Roflumilast, approved in summer 2024 for patients aged 6 and older, is known for its moisturizing formulation and once-a-day dosing schedule in mild to moderate disease states. It also doesn’t have the same stinging or burning as its fellow PDE4 inhibitor, crisaborole. Tapinarof, the newest topical approved for patients aged 2 and older, showed promising results in moderate to severe AD. There are also minimal concerns of folliculitis, which was an adverse effect seen in the initial psoriasis trials for the drug.

The conversation then shifted to systemic therapies, with the clinicians noting dupilumab’s long-term safety data and potential to mitigate type 2 comorbidities. The IL-13 inhibitors of tralokinumab and lebrikizumab can offer narrower targeting and potentially less frequent injections. Furthermore, nemolizumab’s rapid itch relief and unique mechanism target the master itch cytokine, IL-31. Oral abrocitinib and upadacitinib were recognized for their efficacy and speed, especially for patients who may be afraid of shots.

Even with this wealth of treatment choices, Swanson and Eichenfield concluded by emphasizing the need for further research on early intervention strategies, optimal treatment durations, and the role of the microbiome in pediatric AD.