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    Clinical pearls in pediatric dermatology

     

    Dr. Siegfried: Yes. The amount of time that it takes us to get kids access to medication is increasing — particularly for the topical calcineurin inhibitors. Having a generic alternative helps, but there are increasing requirements for step edits and prior authorization.

    Dr. Cordoro: I think something that is profoundly informative is looking at the patient-visit-to-telephone-call ratio. So for the ones who call a lot, we are starting to see with a lot of different medications that, for example, we have one patient visit for atopic dermatitis and nine to 12 phone calls about authorization issues and pharmacy issues. We have not done this formally, but this was just an observation we have recently been making.

    Check out part two of this three part series: Pediatric psoriasis, eczema:Triggers and therapies

    Where do we draw the line between our ability to give excellent care and the lack of ability for the patients to get the medications, and then the staff time and money wasted and time wasted to get the medicines. It’s just becoming so complex and problematic.

    I think we need this kind of data to show companies and carriers that this is just ridiculous when physicians are spending this type of time on these kinds of problems.

    READ: Pediatric trials for AD systemic treatments

    Dr. Siegfried: What about for kids less than two years old, for example, who need a steroid-sparing agent and they can’t get a topical calcineurin inhibitor, what do you do?

    Dr. Cordoro: I used to have no problem prescribing and fighting for prior authorization, but when the Food and Drug Administration put the black box warning on the topical calcineurin inhibitors, it just gave us all pause. Even though many of us don’t believe it’s medically valid and it was based on a theoretical risk, carriers just absolutely use that to their advantage to refuse the medication.

    I will call sometimes, but we were very unsuccessful at getting this medication for kids less than two. We’re just unsuccessful in getting topical calcineurin inhibitors. So, oftentimes I lower the potency of the topical steroid or try to find an alternative like tar. Tar is a big workhorse in my clinic for both psoriasis, atopic dermatitis, and even seborrhea. So small amounts, for example, of liquor carbonis detergens (LCD) 3% or so mixed in petrolatum. There was some back and forth about coal tar as a cutaneous carcinogen several years ago. There have been wonderful studies done about tar for clinical use in dermatology out of the Mayo Clinic. Their 25-year long-term follow-up study1 showed no increased risk of cutaneous carcinoma with tar combined with UV light, so I think the data and efforts like that helped California to keep tar as a therapeutic option.  

    Dr. Siegfried: How do you handle steroid-phobia?

    Dr. Cordoro: My approach has evolved over the years and really varies from patient to patient and family to family. I consider the overall context of the condition and what the parents are telling me. I try to read into what their motivations are and what their beliefs are. I think there are probably two main types of families that I see: There are parents who have been misinformed. They want detailed explanations of pathophysiology of atopic dermatitis, the history of steroids, and the mechanism of action of topical steroids or topical calcineurin inhibitors. Once they understand the mechanism and the rationale for the use, they’re fine with using these therapies.

    Check out part two of this three part series: Pediatric psoriasis, eczema:Triggers and therapies

    The second type of families I see consist of parents that have a fixed false belief about these medications and they just absolutely do not want to consider their use. These are the ones that need to hear simply that these approaches are the gold standard and widely accepted by Western-trained dermatologists and that we vet these therapies through data analysis and expert consensus.

    READ: Part two of Pediatric Dermatology

    When I talk to patients about the fact that these medications have been formalized in the therapeutic guidelines by the American Academy of Dermatology, this helps.

    I have written about this for parents and families because it’s such an issue.2 I often print this article and hand parents a copy. I also tell parents that I am more concerned that they won’t use these topical agents than I am that they will. For the right parent, that resonates. I adopted that approach from Ilona Frieden, and it is very effective.

    The message is that the parent has a child with this difficult skin condition who is missing school, miserable, has dropping grades, the parents are missing work, they are regularly cleaning bloody sheets; so what is the rationale to withhold the medication? There is a risk of untreated disease that outweighs the risks of treatment, and that’s what I try to communicate. I think for some parents you get through, and for others you will never win the battle.

    Check out part two of this three part series: Pediatric psoriasis, eczema:Triggers and therapies

    Dr. Siegfried: Do you have any sound bites for black box topical calcineurin inhibitor phobia?

    Dr. Cordoro: I always tell patients that there is a black box warning and I describe exactly what the truth is in lay terms: The medication was fed to primates in high quantities of active ingredient, some of the primates developed lymphomas. I mention that the warning is based on a theoretical risk and the data derives from nonhuman subjects. I mention that we’re making efforts to get this black box warning overturned. And I give the patient the choice. 

    NEXT References

    Elaine Siegfried, M.D.
    Elaine Siegfried, M.D., is professor of pediatrics and dermatology, Saint Louis University Health Sciences Center, St. Louis, Mo. She ...

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