Management of atopic dermatitis in pediatric patients

For pediatric populations, the onset of complications from atopic disease could have dramatic social, emotional and physical effects on their daily lives.

Fortunately, medical professionals such as Elena B. Hawryluk, MD, PhD, FAAD, FAAP, Massachusetts General Hospital Dermatology, have been loyal to their efforts to manage conditions such as atopic dermatitis and acne in young people. patients.

In his “Tips for Managing Atopic Dermatitis” session which was presented at the American Academy of Pediatrics 2021 Virtual Conference, Hawryluk discussed the complications of diagnosing pediatric patients with atopic disease and how caregivers and clinicians can better treat an affected child.

Hawryluk detailed some of the data found in his presentation in an interview with HCPLive.

HCPLive: Acne vulgaris affects around 9% of the world’s population, but how prevalent is it in pediatric populations? What are some of the complications that younger patients face with this skin disease?

Elena B. Hawryluk, MD, Ph.D.: It is estimated that acne affects around 85% of the population at some point in their lives. In pediatric patients, the prevalence of acne is 35-95%. Adolescence is a time when children gain a more concrete sense of their social structures and themselves and when relationships with peers begin to play an increasingly important role in their lives. Acne during this period can have significant psychosocial impacts, seriously affecting self-confidence and quality of life.

HCPLive: What are some of the acne management or treatment guidelines expressed by institutions such as the American Academy of Dermatology that clinicians generally adhere to? What are the reliable treatment methods and how have these guidelines evolved over time to better treat pediatric patients with atopic disease?

Hawryluk, MD, Ph.D.: The American Academy of Dermatology published an update to the evidence-based management guidelines in the Journal of the American Academy of Dermatology (JAAD) in 2016 and an additional “practical” update on management was published in JAAD by a consensus working group in 2018. Online treatment with topical retinoids and benzoyl peroxide is recommended for most patients, and isotretinoin for patients with very severe cystic or conglobate acne. Antibiotic management is increasingly important and oral antibiotic monotherapy should be avoided – the topic of antibiotic management has changed guidelines in recent years. Hormonal therapies, such as oral contraceptives and spironolactone, are playing an increasingly popular role, even in the pediatric population.

HCPLive: Can you discuss some of the types of acne that a young patient may experience and how the severity of these types of acne may differ from case to case? What are the complications and treatments for each type of acne discussed during your session?

Hawryluk, MD, Ph.D.: There is a 4-point classification system based on evidence-based European guidelines that can be used to classify the type and severity of acne and can help guide treatment in a meaningful way. Class I (mild) is comedonal acne, class II (moderate) is mild to moderate papulopustular acne, class III (severe) is severe papulopustular acne and moderate nodular acne, and class IV (very severe) is severe lumpy / cystic acne and conglobate acne.

Scars, whether atrophic or hypertrophic, and pigment changes can present as longer term problems due to severe, undertreated or untreated acne.

Some other forms of “acne” include “fungal acne” which is caused by yeast (Malassezia) and looks a little differently (ie itchy and monomorphic along the hairline / hairline). forehead / chest / back) and can be treated with an antifungal shampoo. .

Finally, there are rare cases where acne can be a good sign – as is the case with acneiform breakouts secondary to EGFR inhibitors. When children take these drugs, acneiform rashes have been associated with positive outcomes and strongly correlated with survival.

HCPLive: What role do patients, caregivers and clinicians play in establishing an effective treatment plan? What can all parties involved in managing a skin disease such as acne vulgaris do?

Hawryluk, MD, Ph.D.: Children may be reluctant to tell clinicians about their acne out of embarrassment or a lack of knowledge of treatment options. A recent study has shown that when it comes to acne, patients are overwhelmingly dissatisfied with the information they receive (Tan et al, J Drugs Dermatol, 2021). It is important to discuss acne and treatment options regularly, as acne can have profound effects on mental, emotional, and social well-being, especially in children. Setting realistic expectations can improve treatment adherence, and the simpler the routine, the more likely the patient is to adhere to it.

Acne treatment requires patients to be diligent in their skin care routine, so nonadherence is a major obstacle to successful treatment. Caregivers can help by using positive reinforcement at home to encourage the use of prescribed medications. Prescribers can incorporate patient preferences when developing the plan to maximize adherence.

HCPLive: Can you touch on some of the new therapies that are detailed in your session?

Hawryluk, MD, Ph.D.: Several emerging therapies are on the horizon, including new formulations of existing drugs and new modalities. During this talk, I provide an overview of a novel narrow spectrum tetracycline with anti-inflammatory properties with a narrow side effect profile. There are new formulations of antibiotics in foam form, topical hormonal therapies and a 4th generation topical retinoid. the drugs are new and the cost, accessibility and lack of direct comparison with other acne treatment modalities must be taken into consideration.

HCPLive: How do you design effective treatment plans for affected patients? What can be done to better treat this patient population in the years to come, and how would you like this area of ​​research to evolve over time?

Hawryluk, MD, Ph.D.: It is important to first consider the type of acne in your patients (comedones, inflammatory, both) and determine the severity. There are many algorithms available online to help select the appropriate medications. The 2018 Practice Management Guidelines that were published in the Journal of the American Academy of Dermatology have a nice summary table with associated images to help make this decision.

As always, close follow-up with reassessment of your treatment plan is necessary – if it doesn’t work, change it! Attention to treating acne effectively and early would be beneficial in the years to come in reducing the amount of scarring and more permanent changes that are difficult to treat. Research efforts focused on improving the tolerance of existing therapies will also be helpful.

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