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    Pediatric psoriasis, eczema: Triggers and therapies


    Assessing systemic treatments

    Dr. Siegfried: I have a very high index of suspicion for herpes, and have been frequently surprised by positive PCR or viral cultures from scrapings of clinically eczematous skin. I now look much closer for herpes, and have diagnosed several kids with what I call “herpes incognito,” because it doesn’t present with the classic punched-out lesions.  I think I had been under-recognizing it, and in some kids with severe eczema, I think herpes is a trigger in the same way that colonization with Staph aureus or pityrosporum can trigger eczema.  I first became aware of herpes incognito because the viral skin infection became more obvious in kids treated with systemic immunosuppressants.  Then I started looking for it before considering a systemic drug. So, that brings me to my next question, how do you know when a kid needs systemic treatment?

    Dr. Cordoro: I don’t have formal criteria upon which I base the decision on whether to opt for systemic therapy for atopic dermatitis or psoriasis. I approach every patient individually.

    Some patients I consider candidates for systemic therapy at their very first appointment. That can be based on disease severity or presence of comorbidities, such as arthritis. Equally importantly is the impact on the quality of life. If the psoriasis patient or the atopic dermatitis patient is miserable, failing to thrive, missing work or school days, they absolutely may get a systemic therapy on day one, appointment one.

    READ: Childhood skin disease has unique challenges

    Most of the time, I try to treat with combination topical regimens for both atopic dermatitis and psoriasis before deciding on the next steps. I think this is important because during this treatment time, you begin to understand the family dynamic, develop rapport, and establish a relationship with the family before you put them on a medication that requires a lot of monitoring, bloodwork and trust.

    NEXT: 3 things to consider before using systemic therapy


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