Treatment Considerations for Pediatric vs Adult Patients With Atopic Dermatitis

With new agents increasingly becoming available to patients with atopic dermatitis and the clinicians who provide care for them, the treatment paradigm is shifting.

In this interview with First Report Managed Care, Dr Larry Green walks through how patients’ ages affect treatment considerations and related challenges, as well as where the future of care may be headed as more drugs receive FDA approval.

Can you discuss the prevalence of atopic dermatitis in the United States?

About 7% to 7.5% of the population in the United States has atopic dermatitis. Up to 20% of children have atopic dermatitis, so there is a much higher percentage in children.

The main issue with atopic dermatitis is having an impaired skin barrier, which can cause bacteria to overgrow, especially Staphylococcus bacteria. These patients tend to have more pathogenic bacteria on the skin compared to people who do not have atopic dermatitis. 

The prevalence of atopic dermatitis is thought to be higher in children because their skin barrier is so much more reactive to the environment. Children are more prone to skin breakdown.

What are some key considerations when you decide on a treatment plan for pediatric vs adult patients?

Patients need to repair that skin barrier and keep it repaired. Moisturizers with ceramides, prebiotics, and probiotics can help repair the skin. What I prioritize is long-term care so the patient’s skin microbiome stays diverse, their skin barrier stays intact, and their chance of experiencing another flare is limited.

Treatment depends on how old pediatric patients are. With younger patients, you are coordinating with the parents on the treatment plan. With teenagers, you are coordinating with both the patient and the parents.

The most important thing with teenagers is compliance. Using moisturizer on a regular basis, especially moisturizer that helps heal the skin barrier, is so important in the prevention of atopic dermatitis. With younger children, the parents can apply it and stay on top of it, and adults hopefully will be compliant as well, but teenagers are so busy. It is hard for them to remember to take care of themselves.

When deciding on a treatment plan, you want to consider the age of the patient and stress the importance of diligence, protection, and prevention. You want to clear up their atopic dermatitis, but it is going to return quickly if they do not take care of themselves after the treatment flare.

Treatment is largely the same for children and adults. Dupilumab is the only biologic available for younger children with severe atopic dermatitis right now. We have ruxolitinib cream, the topical JAK inhibitor, for people 12 years of age and older. Ruxolitinib cream works well and takes the stress away from potentially misusing topical steroids. But under 12 years of age, patients without severe disease are still using topical steroids.

Can you provide some insight into what patients prioritize when considering their treatment options?

The simpler the treatment, the better. For people with mild-to-moderate atopic dermatitis, using multiple medications—one on the face and neck and another one on the legs or arms, for instance—and then moisturizers on top of that is very complicated.

Patients with severe disease may use medications like dupilumab, tralokinumab, or some of the newer JAK inhibitors. In a way, it is easier to treat severe atopic dermatitis, because patients just take an injection or a pill and moisturize. It is much easier for a child or even an adult to take an injection once every 2 weeks vs apply different creams to different body regions once or twice daily.

How have recent drug approvals impacted your practice?

Topical steroids, if not used appropriately, can cause thinning of the skin, and stretch marks. That is important in teenagers, especially. Also, steroids can be addictive in that once your skin is used to having them, you must keep using them. Topical steroids cannot be used on the face, intertriginous areas, behind the knees, or on the neck.

Ruxolitinib cream changed the paradigm because it can be used anywhere on the body and does not produce the side effects of steroids.

Where do you see the future of care headed as more treatments come to market?

A trend we will see more of in the future is less reliance on topical steroids for treating atopic dermatitis. I think it will become easier to treat atopic dermatitis topically, with medications like ruxolitinib cream changing the paradigm.

There are newer creams, which can be used anywhere on the body and do not incur the same risks as steroids, that hopefully will be FDA approved the next 3 or 4 years. I think newer medicines will be indicated for lower age groups, and treatment options for mild disease will catch up to those for severe disease.

Ruxolitinib cream is the harbinger of much better things to come that will make it easier to treat mild-to-moderate atopic dermatitis. There are roflumilast and tapinarof, which may be coming in the next few years if the clinical trials show they work. If these treatments pan out, they will make a big difference as well.

About Dr Green

Lawrence J Green, MD, is a clinical professor of dermatology at George Washington University School of Medicine in Washington, DC.