What’s New in Pediatric Dermatology With Elizabeth (Lisa) Swanson, MD

From hemangiomas to segmental vitiligo, atopic dermatitis to warts, clinicians are always presented with challenging cases in pediatric dermatology. At Winter Clinical Miami, held February 17-20, 2023, in Miami, Florida, Elizabeth (Lisa) Swanson, MD, from Ada West Dermatology and St Luke’s Children’s in Idaho, presented a few such case studies in her lecture, “What’s New and Hot in Pediatric Dermatology!”¹

Swanson also touched on the current treatment landscape for common pediatric skin diseases and discussed what’s up-and-coming in the pipeline.

Swanson began her lecture with a variety of case studies. The first patient was a 7-week-old infant whose lip hemangioma was barely present at birth but grew rapidly and began ulcerating. Special-site hemangiomas should always be treated, Swanson urged, including those on the lips, eyelids, nose, or genital area.

As far as treatment options for hemangiomas, Swanson told attendees that propranolol is still a solid choice, administered 2 mg/kg/day divided either twice a day (BID) or 3 times a day (BID often more convenient). It is most effective when given in the first year of life. The medication should always be taken with food to avoid hypoglycemia. Clinicians should provide propranolol counseling to parents to set expectations. Patients with respiratory infections may wheeze while on the medication, there may be a slight decrease in heart rate and blood pressure, patients may experience strange dreams or sleep disturbances, and the minty taste of generic propranolol may bother some babies by triggering reflux.

Clinicians could also consider oral nadolol, which was actually found in Canadian study to be non-inferior to propranolol, Swanson said. However, US clinicians are hesitant to adopt nadolol for a few reasons. First, it has to be compounded, which drives up cost and, secondly, it comes with a constipation warning. A patient in the Canadian study became constipated and died due to toxic levels of nadolol in the patient’s system, so Swanson advises to discontinue treatment if constipation is present for 3 days.

Topical timolol could be considered to treat superficial hemangiomas, according to Swanson.

The next case comprised a patient with chronic bullous disease of childhood who presented with rosettes of blisters all over her arms, legs, and cheeks. After appropriate labs, treatment of choice is dapsone, Swanson said, however be cautious of methemoglobinemia, which occurred in her patient case. The patient was admitted to the pediatric intensive care unit. After polling some colleagues and discussing with the parents, Swanson initiated treatment with dupilumab, which resulted in significant improvements at 2 months.

One concern when considering dupilumab for children is vaccines, as live vaccines are to be avoided per the FDA label. Although in trials, investigators stopped treatment for 12 weeks, administered the vaccine, and then restarted dupilumab after 4 weeks, there is no solid answer, Swanson said.

Swanson also provided tips for clinicians to successfully administer the shot: Follow the HELP method (Hug, Electronic Device, Lollipop, and Prize Box). Have the parent undress the child as soon as they arrive and play something fun on an electronic device. Then, when it’s time for the injection, the clinicians arrives, and the child sits in the parent’s lap facing the parent in a hug. This exposes the upper outer arms and upper thighs of the child. Give them a lollipop, administer the injection, and celebrate with a prize.

Swanson also presented patient cases of segmental vitiligo, warts, and atopic dermatitis in her talk, in which she employed topical ruxolitinib combined with polypodium leucotomos, WartPeel, and the Aron regimen, to treat, respectively.

The Aron regimen for kids with atopic dermatitis was first created by Dr. Aron in the United Kingdom decades ago but was brought back into popularity by Peter Lio, MD, clinical assistant professor of dermatology and pediatrics at Northwestern University Feinberg School of Medicine in Chicago, Illinois. It involves a compounded mix of betamethasone valerate, mupirocin, and vanicream or plastibase. It is applied up to 5 times a day and tapered depending on flares and is most effective for babies and toddlers with persistent facial eczema.

In a video interview with Dermatology Times®, Swanson provided additional updates from her Winter Clinical Miami lecture, as well as her advice to colleagues for interacting with pediatric patients.

This transcript has been edited for clarity and length.

Swanson: So much new in the world of pediatric dermatology—new and novel treatments for atopic dermatitis, hemangiomas, childhood blistering diseases, warts. We are practicing during the Golden Age of dermatology, and that’s especially true for our pediatric patients. It’s really a wonderful time to be in the field.

So much depends on the age of the pediatric patient…I think it’s always important to try to talk to the child, you know, unless they’re a baby, but try to bring them into the conversation. Ask them what grade they’re in, if they like their teacher—always a complicated subject if they’re homeschooled, because then they have to like their teacher—ask them what sports they like, kind of dive into the things that they’re interested in, make them feel a part of the visit and a part of the conversation. Even if they’re not the head decision maker in the room, I still want them to feel included. I want to know how their skin disease is affecting them. It’s really important to talk to the patient even when it is a child.

The world of atopic dermatitis treatments is just exploding. We’ve had [dupilumab] for the past 6 years. We have [upadacitinib] approved down to age 12 for moderate to severe atopic dermatitis. [Abrocitinib’s] label just got expanded down to the age of 12, that’s exciting. We have topical [ruxolitinib] down to the age of 12, hopefully soon to be younger. We have a couple of topical medicines approved in the psoriasis space that we expect to see approved for atopic dermatitis, medicines like roflumilast and tapinarof. We have so many more options to tell our patients about which makes my job so much better.

I’m definitely excited to see roflumilast and tapinarof approved for atopic dermatitis and approved in younger age groups. Currently, roflumilast is approved age 12 and up for plaque psoriasis and tapinarof, it’s just 18 and up for plaque psoriasis too. I’d love to see those medicines approved in younger age groups and for atopic dermatitis. I know there’s a foam version of roflumilast that’s coming, really excited for that to treat things like scalp psoriasis and seborrheic dermatitis. So really excited to actually have more in the topical space. For the past 10 years, we’ve had all these wonderful biologics and systemic therapies and, oh my gosh, am I grateful for those, but it doesn’t beat a really good topical medicine that certainly is very appealing to a patient and their family starting out on a treatment course for atopic dermatitis or psoriasis.

I think the biggest thing is that it’s so important to treat pediatric patients with skin disease. I think sometimes people who aren’t comfortable necessarily with the pediatric population, who spend most of their clinic day seeing adults, I think sometimes they’re a little bit shy about the kids or a little bit nervous with the kids, but these kids are really struggling. They have bad atopic dermatitis. They have bad psoriasis. They get bad hemangiomas, they get bad hidradenitis suppurativa…They really need good therapy because they have they have a long life to live and we want to make it their best one.

Reference:

Swanson E. What’s new in pediatric dermatology. Presented at Winter Clinical Miami 2023; February 17-20, 2023; Miami, FL.