50 years of pediatric dermatology

August 29, 2017|Pediatric News

Psoriasis has been a condition that has been “behind the revolution,” in that no biologic agent was approved for pediatric psoriasis in the United States until several months ago, lagging behind Europe and elsewhere in the world by almost a decade. Adult psoriasis has been recognized to be associated with a broad set of comorbidities, including obesity and early heart disease, and there is now research on how children are at risk as well, and new recommendations on how to screen children with psoriasis. Moderate to severe psoriasis in adults is now tremendously controllable with biologic agents targeting TNF-alpha, IL 12/23, and IL-17. Etanercept has been approved for children with psoriasis aged 4 years and older, and other biologic agents are under study.

Atopic dermatitis now is ready for its revolution! AD has increased in prevalence from around 5% of the pediatric population 30-plus years ago to 10%-15%. Treatment of most individuals has remained the same over the decades: Good skin care, frequent moisturizers, topical corticosteroids for flares, management of infection if noted. The topical calcineurin inhibitors (TCIs) broadened the therapeutic approach when introduced in 2000 and 2001, but the boxed warning resulted in some practitioners minimizing their utilization of these useful agents.

Dr. Lawrence F. Eichenfield with a young patient.

Unfortunately, the combination of minimal new therapies over decades and phobias about potential side effects of topical steroids and TCIs has resulted in a tremendous amount of undertreatment of AD, with many children walking around (and not sleeping too well) with high body surface area involvement, secondary infections, and sequelae including ADHD, anxiety, and depression. The pediatric dermatology community, together with adult dermatology (and allergy) specialists, are now working aggressively to minimize AD’s effects. New initiatives, including improving education of patients and families with learning tools, are being developed, based on studies showing how they can impact disease. A new agent, a topical PDE-4 inhibitor (crisaborole), was recently approved for AD for ages 2 years and older. This drug is not a corticosteroid nor a TCI, and was approved without a specific time limitation for its use. In addition, the first prospectively designed biologic agent developed for AD, a receptor blocker that influences IL4 and IL13, has been approved in adults with moderate to severe AD, and is already under study in children and adolescents. The use of biologic agents and/or small molecules targeting the inflammation of more severe AD in children may transform management.

It has been recognized for years that children with AD have higher risk of developing food allergies than children without AD. A changing understanding of how early food exposure may induce tolerance is changing the world of allergy and influencing the care of children with AD. This is where the peanut butter (or other processed peanut, such as “Bamba”) may be life saving. New guidelines have come from the National Institute of Allergy and Infectious Diseases recommending that infants with severe eczema (or egg allergy, or both) have introduction of age-appropriate peanut-containing food as early as 4-6 months of age to reduce the risk of development of peanut allergy. It is recommended that these infants undergo early evaluation for possible sensitization to peanut protein, with referral to allergists for skin prick tests or serum IgE screens (though if positive, referral to allergists is appropriate), and assess the safety of going ahead with early feeding. It is hoped that following these new guidelines can minimize the development of peanut allergy.

The future

Where will pediatric skin disease, or more importantly, skin health over a lifetime be in 50 years? Can we cure or prevent the consequences of our lethal and life altering genetic diseases such as epidermolysis bullosa or our neurocutaneous disorders? Will our new insights into birthmarks (they are mostly somatic mutations) allow us to form specific, personalized therapies to minimize their impact? Will we be using computers equipped with imaging devices and algorithms to assess our patients’ moles, papules, and nodules? Will our vaccines have wiped out warts, molluscum, and perhaps, acne? Will we have cured our inflammatory skin disorders, or perhaps prevented them by interventions in the neonatal period? No predictions will be offered here, other than that we can look forward to incredible changes for our future generations of health care practitioners, patients, and families.

Dr. Eichenfield is chief of pediatric and adolescent dermatology at Rady Children’s Hospital–San Diego and professor of dermatology and pediatrics at the University of California, San Diego. Dr. Eichenfield has served as a consultant for Anacor/Pfizer and Regeneron/Sanofi. Email him at pdnews@frontlinemedcom.com.