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Atopic Dermatitis in the Pediatric Practice: Working With Caregivers

  • Authors: Peter A. Lio, MD; Smita Aggarwal, MD; Sarah L. Chamlin, MD
  • CME Released: 12/14/2018
  • Valid for credit through: 12/14/2019
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Target Audience and Goal Statement

This activity is intended for pediatricians, dermatologists, and primary care physicians.

The goal of this activity is to inform clinicians regarding the assessment and management of pediatric patients who have moderate to severe atopic dermatitis (AD) through an examination of case studies, current treatment, and practical knowledge to support shared decision-making.

Upon completion of this activity, participants will be able to:

  • Have greater competence related to
    • The assessment of patients when diagnosing moderate to severe AD
    • Shared decision-making to formulate comprehensive treatment plans for moderate to severe AD
  • Demonstrate improved performance associated with
    • Their ability to recognize when to refer patients for systemic/biologic treatment


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  • Peter A. Lio, MD

    Clinical Assistant Professor
    Dermatology and Pediatrics
    Northwestern University
    Feinberg School of Medicine
    Chicago, Illinois


    Disclosure: Peter A. Lio, MD, has disclosed the following relevant financial relationships:
    Served as an advisor or consultant for: AOBiome; Franklin; Galderma Laboratories, L.P.; Genzyme Corporation; Johnson & Johnson Pharmaceutical Research & Development, L.L.C.; L'Oreal; Menlo Therapeutics Inc.; Pfizer Inc.; Pierre Fabre; Realm; Regeneron Pharmaceuticals, Inc.; Sanofi; Theraplex
    Served as a speaker or a member of a speakers bureau for: Genzyme Corporation; L'Oreal; Pfizer Inc.; Pierre Fabre; Regeneron Pharmaceuticals, Inc.; Sanofi
    Received grants for clinical research from: AOBiome


  • Smita Aggarwal, MD

    Pediatric Dermatologist
    Medical Dermatology Associates
    Chicago, Illinois


    Disclosure: Smita Aggarwal, MD, has disclosed no relevant financial relationships.

  • Sarah L. Chamlin, MD

    Pediatrics and Dermatology
    The Ann and Robert H. Lurie Children's Hospital of Chicago Northwestern University
    Feinberg School of Medicine
    Chicago, Illinois


    Disclosure: Sarah L. Chamlin, MD, has disclosed the following relevant financial relationships:
    Served as an advisor or consultant for: Intraderm Pharmaceuticals; L'Oreal; Menlo Therapeutics Inc.


  • Shari J. Dermer, PhD

    Scientific Director, Medscape, LLC


    Disclosure: Shari J. Dermer, PhD, has disclosed no relevant financial relationships.

  • Heather Lewin, MAT

    Associate Scientific Director, Medscape, LLC


    Disclosure: Heather Lewin, MAT, has disclosed no relevant financial relationships.

  • Erika Czopkiewicz, RN

    Patient Caregiver
    Rush University Medical Center


    Disclosure: Erika M. Czopkiewicz, RN, has disclosed no relevant financial relationships.

CME Reviewer

  • Amy Bernard, MS, BSN, RN-BC, CHCP

    Lead Nurse Planner, Medscape, LLC


    Disclosure: Amy Bernard, MS, BSN, RN-BC, CHCP, has disclosed no relevant financial relationships.

Peer Reviewer

This activity has been peer reviewed and the reviewer has disclosed no relevant financial relationships.

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Atopic Dermatitis in the Pediatric Practice: Working With Caregivers

Authors: Peter A. Lio, MD; Smita Aggarwal, MD; Sarah L. Chamlin, MDFaculty and Disclosures

CME Released: 12/14/2018

Valid for credit through: 12/14/2019


[START 264100_01_RT_Lio_110518.mp3] Peter Lio, MD: [00:00:07] Hello. I am Peter Lio, Clinical Assistant Professor of Dermatology and Pediatrics at Northwestern University Feinberg School of Medicine here in Chicago, Illinois. Welcome to this program titled Atopic Dermatitis in the Pediatric Practice: Working with Caregivers. [00:00:22] Joining me today are Dr Smita Aggarwal, who is a pediatric dermatologist at Medical Dermatology Associates of Chicago, and Dr Sarah Chamlin, who is a Professor of Pediatrics and Dermatology at Northwestern Feinberg School of Medicine. Welcome. Smita Aggarwal, MD: [00:00:36] Thank you. Dr Lio: [00:00:37] This program will include a discussion of off-label treatments and investigational agents not approved by the FDA for use in the United States. Atopic dermatitis, also referred to as eczema or atopic eczema, is common chronic inflammatory skin disease that primarily affects infants and children. In fact, it is the most common chronic skin disease in children. It is estimated that 10% to 20% of kids in the United States have atopic dermatitis. [00:01:08] Some 60% of children experience the onset of atopic dermatitis in the first year of life, and about 85% will have onset of disease by age 5 years. These patients are going to present initially to pediatrics vastly more than they are going to see a dermatologist at first. Although the majority of children with atopic dermatitis, probably about two-thirds, have mild disease, that still leaves one-third of patients with moderate to severe atopic dermatitis that can frequently be much more difficult to manage. [00:01:38] Many of these children with moderate to severe atopic dermatitis are first seen and diagnosed in pediatric practices. My colleagues and I are going to talk through a case of pediatric atopic dermatitis to help you improve management of these sometimes challenging cases. We are also going to be joined by Erika, the parent of a child with moderate to severe atopic dermatitis. [00:02:00] Let us talk about our case. Luke is a 6-year-old boy who has an itchy rash on his arms, legs, and neck that show signs of excoriation. Some of the lesions are oozing and crusted. Luke's parents are particularly concerned because he is up at night scratching causing difficulty in getting up for school the next day. His parents have actually received a call from his first grade teacher saying that he was inattentive in class. [00:02:24] His mom said that this has been going on for a couple of months at least. She does remember that he had an instance of eczema when he was a baby. That was managed with the use of moisturizers and some bathing techniques. His mom said she tried to get him to use a heavier moisturizer on his rash, but he was resistant saying it did not help and he did not like the feel of the cream. [00:02:44] His mom also mentioned that her brother has had bad eczema, and she even had some eczema as a child. Dr Aggarwal, what are your impressions about Luke from what we have just heard? Dr Aggarwal: [00:02:54] Luke is very typical of children that are often referred to us from pediatric practices. As I heard Luke's story, there were several things that point to a diagnosis of atopic dermatitis, first being the location of his dermatitis on his extremities and his neck. Those are classically involved locations. His rash appears to be very pruritic, which is a cardinal feature of atopic dermatitis. He seems to have some superficial crusting, which is concerning for a skin infection. [00:03:20] You mentioned that his first dermatitis was during infancy, which is a common age of presentation for atopic dermatitis. It seems to be a family history of atopic dermatitis in both mom and brother. When mom mentioned about his sleep, it was very important. Sixty to 80% of children with atopic dermatitis have sleep disturbance. They can significantly impair their quality of life. [00:03:44] There have been recent reports demonstrating the association between sleep disturbance and ADHD correlating with both sleep deprivation and severity of disease. Dr Lio: [00:03:54] Dr Chamlin, what are your thoughts on the severity of Luke's atopic dermatitis from what we have heard and seen? Sarah L Chamlin, MD: [00:04:00] His atopic dermatitis looks severe. It looks like it is widespread covering 30% to 40% of his body. The plaques themselves look thickened, lichenified. They are eroded, crusted. Clearly, he is very uncomfortable because of all the excoriations. I would not be surprised if he had severe sleep issues or trouble falling asleep and staying asleep because of the itch. That is what interferes with school performance due to his sleep deprivation. Dr Lio: [00:04:26] What are some of the essentials that the pediatrician should review with the parents and the patient? Dr Aggarwal: [00:04:32] I think it would be very helpful for pediatricians to counsel families about even basic skin care, starting with bathing and what we call the soak and smear technique. It can be helpful for pediatricians to review which soaps to use, to avoid fragrance soaps, to utilize soap as cleansers, and to avoid bubble baths. [00:04:50] The soak and smear technique, as we call it, is where after getting out of the bathtub, you immediately layer the skin with a thick blend of emollient without first drying the skin. Now, emollients over-the-counter come in 3 varieties: ointments, creams, and lotions. [00:05:04] The ointments are going to be the thickest and the greasiest. These are the ones that are best suited for our children with atopic dermatitis. There are now some specialized emollients over-the-counter that have additional components to help prepare the skin barrier like ceramides and lipids. Those can be very useful as well. Wet wraps are another very useful tool for pediatricians to teach families how to utilize during severe flares. They can be very, very healing and soothing for the skin. Dr Lio: [00:05:30] Dr Chamlin, what are your thoughts on addressing inflammation? Dr Chamlin: [00:05:33] It is really important to address inflammation. If you skip this step, you fail with your treatment plan. You have to thoroughly address inflammation. Sometimes, this inflammation is very evident with the dermatitis itself. We can all see that. Eczema is known to be the itch that rashes. Some kids are just itchy, and they bring the dermatitis out. [00:05:53] Goals of treatment are 3-fold. When we are treating atopic dermatitis, we want to treat the flare itself. We want to prevent further flares. Importantly with thorough comprehensive care, we decrease the severity of disease over time. Dr Lio: [00:06:08] Bacterial infections have been really an interesting topic. I feel like the microbiome, in general, is a hot topic. We know that most patients with moderate and severe atopic dermatitis have secondary colonization if not true infection, part of that due to the barrier damage from scratching and rubbing of the skin. [00:06:26] What has been interesting is the story about bleach baths and ways we approach this. Initially, the thinking was that dilute bleach baths will help. They really do seem to help a number of patients. The thought was that they were antimicrobial, decreasing some of the staph bacteria. That has been a little bit of an up and down ride, where we have seen some paper say it probably does not affect the bacteria at least in some of the patients studied, and may actually have some anti-inflammatory and maybe even some barrier repair properties. [00:06:52] Whatever reason it is working, it does seem to help some of these patients. One of the nice ways to integrate dilute bleach baths is to tell the family that it is a little bit like turning your bathtub into a swimming pool in your home. Just a little bit of that chlorination seems to have a soothing effect for a lot of patients. In the meantime, I think we are still looking for ways to help better balance the skin bacteria. Dr Chamlin: [00:07:12] It is extremely important for the provider to evaluate how both the patient and the parent are sleeping. Children with atopic dermatitis have trouble falling asleep and staying asleep. Initially, this is because kids are really itchy. Later, it becomes a learned behavior. These kids wake up even when their skin is clear. [00:07:30] This sleep dysfunction really leads to decreased deep sleep. This deep sleep is really critical to have our brain's battery recharge. These kids do not get the deep sleep that they need. It is always important to remember that the sleep dysfunction is not just for the patient themselves. It is the whole family that is up at night trying to soothe the effect of child to asleep. Dr Lio: [00:07:53] I feel like that is so true. You see the whole family come in, and everybody looks a little bit like a zombie. It is so important. [[insert additional content segment 1 [*] from time code 00:00 to 01:24]] [[insert patient segment]] Let us return to our patient case. Luke's pediatrician prescribed hydrocortisone 2.5%, low potency topical corticosteroid. They asked them to return in about 6 weeks. When he returned, he was only slightly improved. It was clear that some of the lesions on his neck actually were now truly infected. [00:08:19] Dr Aggarwal, what are your thoughts on Luke's treatment so far? Dr Aggarwal: [00:08:23] It seems the pediatrician took the right first step in prescribing a low potency topical corticosteroid. However, there are a few other pieces of the treatment regimen that are important to make sure were addressed. [00:08:33] Did the pediatrician go over gentle skin care, how to apply emollients, how much is needed, and proper bathing techniques? You mentioned that he is only slightly better in spite of using several weeks of a topical medication. It makes me wonder if the parents have been able to adhere to his topical regimen. Lastly, have other triggers of his atopic dermatitis been addressed and eliminated? Dr Lio: [00:08:56] Let us assume that the pediatrician did a good job talking about moisturization and bathing. What is the next step in terms of topical steroids and managing atopic dermatitis from there? Dr Aggarwal: [00:09:07] Topical corticosteroids are still considered the first-line topical treatment for atopic dermatitis. We choose a potency of topical corticosteroid based on various factors: the age of the patient, the location of their dermatitis, and the severity. Topic corticosteroids come in 7 classes. For moderate to severe flares, we often do have to go to a mid- to high-potency topical steroid at least for a short period of time. [00:09:32] Typically during those flares, I will recommend using them twice a day to the affected areas for up to about 2 weeks. You can stop sooner if improved. Certain areas like the eyelids, facial skin, the genital region, we typically rely on lower potency topical corticosteroids or even steroids-bearing agents. Dr Lio: [00:09:50] You bring up this question of adhering to the regimen, which can be difficult for a lot of patients and families. Dr Chamlin, how do you assess this? What should the pediatrician do to assess and discuss it with the family? Assessment of Adherence Dr Chamlin: [00:10:02] It is important to ask parents to bring all the medications including the emollients to clinics. You can see what they are actually using. I find very often they have used little of the prescription medication. I check the date of the last fill and see if they have refilled it. It really helps us make treatment decisions. Do we want to increase the potency of a topical corticosteroid or have them use what they already have and use it appropriately? [00:10:26] I demonstrate how much medication a parent should apply to their child. I take the parent's own tube. I squirt a ribbon of the corticosteroid down my finger, and then I apply it to the child's. Then, I apply the emollient over the top. Most often, the parent and the child look at each other and admit that they were not using nearly enough. Dr Lio: [00:10:49] I think that is such a next-level tip that you can actually show the family how to put it on. That has been my experience as well. People say oh, my gosh. I was only putting the tiniest little bit trying to cover the body. You do need a little bit more to get the medicines where it needs to be. Dr Chamlin: [00:11:03] I also really thoroughly review potential triggers for flares of their dermatitis. Those can include contact allergens. I want to make sure if I have their products in front of me that they are using a fragrance-free soap and an emollient that is very simple and basic. [00:11:19] I have handouts and I really counsel families to make sure they are using fragrance-free detergents, no dryer sheets, that the clothing they dress their children in feels soft, and avoiding temperature extremes. Super cold weather, really hot weather, kids will flare. Also, the change in the seasons seems to be the most common trigger for most patients. If a patient has proven allergens, they should really avoid those things: cats, dogs, other proven allergens. Patient Case: Luke Follow-Up Assessment Dr Lio: [00:11:48] Luke's pediatrician explains the proper use of topical corticosteroids. His mom asks if it is okay to keep using steroids for such a long time. The pediatrician also recommends that Luke use an intermittent steroid sparing treatment such as a topical calcineurin inhibitor or a topical crisaborole. His mom leaves with a new prescription and an appointment to follow up in about 6 weeks. [00:12:10] When he returns in 6 weeks, there are some improvement in the crusting of his lesions. Some look like they are actually finally starting to heal, but there are still new lesions appearing on his legs and neck. His mom says that the whole house is still up because he cannot sleep through the night due to his itch. Is this the time to refer Luke to a dermatologist or a pediatric dermatology specialist? Dr Chamlin: [00:12:30] Absolutely. Dr Aggarwal: [00:12:30] Yes, definitely. Dr Chamlin: [00:12:32] I think that the pediatrician has exhausted what they are comfortable with and even gone beyond that. They have taken the next step to ramp up treatment. Most pediatricians will not prescribe systemic immunosuppressants for their children. It is not clear if this patient needs that yet. He really does need a specialist. Eczema ‘Boot Camp’ [00:12:50] When you come to a pediatric dermatologist or an eczema specialist, most often, a child like this will get what we call Eczema Boot Camp . Boot Camp is optimizing dry skin care, inflammation treatment with topical corticosteroids initially, addressing bacteria with bleach baths, and systemic antibiotics if needed, and making sure they are sleeping okay, plus doing wet wraps as well is really helpful for a kid like that. Dr Lio: [00:13:16] The Boot Camp is a powerful thing, but it does take some teaching and time. It takes some experience and familiarity with how to counsel a patient through that. It can be pretty transformative for these people. Dr Chamlin: [00:13:26] It can be a full-time job for the parent. Dr Lio: [00:13:28] Definitely. How do we determine then which children are candidates for systemic treatment? Maybe, the final level up after they have failed the basic topicals, they have failed the Boot Camp, or maybe improved with Boot Camp but did not stay clear. What happens next? Systemic Treatments Dr Aggarwal: [00:13:41] There are several ways we can evaluate these children to see if they need to take that next step. Do they have moderate to severe atopic dermatitis? Have they been adherent to their regimen and in spite of weeks and weeks of treatment, it just is not working? Is their quality of life impaired even with their strenuous regimen? Lastly, is the family able to continue with their current treatment plan? Dr Lio: [00:14:03] What kind of options would you use? If they meet those criteria, where do we go with systemics for our pediatric patients because we know there is not a lot that is on label for this group? [[Slide ]]Systemic Agents Dr Aggarwal: [00:14:13] We do have a few options. Methotrexate and cyclosporine are the most commonly used systemic agents in children with atopic dermatitis, although they are both considered off-label. Cyclosporine tends to have the quickest onset of action. It is a great choice to quickly suppress severe flare. [00:14:30] Regarding the side effect profile of this medication, typically, we like to transition off of it after about 2 to 3 months of therapy and onto a safer immunosuppressant such as methotrexate or back to their topical regimen. [00:14:42] One of the newest treatments in our eczema toolbox is dupilumab, an anti-interleukin-4, interleukin 13 biologic agent that is currently approved for adult patients with moderate to severe atopic dermatitis aged 18 and up. It is currently in clinical trials for pediatric patients. Excitingly, it was just approved in patients 12 and older for moderate to severe asthma. Dr Lio: [00:15:05] What about systemic corticosteroids like prednisolone or prednisone? Dr Aggarwal: [00:15:10] Typically, those can be used for severe flares to really help them get through that tough time while you are transitioning them to another safer immunosuppressant. They are not typically used for long-term management because of their side effect profile. [[insert additional content segment 2 [#] time code 01:25 to end]] Concluding Remarks Dr Lio: [00:15:26] Fortunately, most atopic dermatitis is more mild. It generally is easier to diagnose and treat. As we have seen today, not all cases are so easy. Some of the more moderate and severe cases really demand a higher level of care. This is going to require a care team with experience. [00:15:42] One of the most exciting things for people interested in atopic dermatitis, including parents and patients and the rest of the family, is that we are in this incredibly exciting time with tremendous leaps in both understanding and therapeutic options just on the horizon. Together, I am really hoping that we can learn and share ideas to get our patients the best possible care. Thank You [00:16:02] Dr Chamlin, thank you so much. Dr Aggarwal, thank you so much for participating in this activity. I would like to thank you all for participating with us today. Please continue on to answer the questions that follow and complete the evaluation. [END 264100_01_RT_Lio_110518.mp3]

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