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Multiple modalities enable successful treatment of atopic dermatitis in children

Las Vegas — Topical corticosteroids are still the mainstay of therapy for pediatric atopic dermatitis (AD), but dermatologists have an array of other options at their disposal to use for steroid sparing or in challenging situations.

Speaking at the 2011 Fall Clinical Dermatology Conference, pediatric dermatologists Anthony Mancini, M.D., and Sheila Friedlander, M.D., discussed the role of topical calcineurin inhibitors (TCIs), barrier repair agents, bleach baths and wet wraps in the management of pediatric AD.


Dr. Mancini
Dr. Mancini reminds dermatologists that in children with AD, inflammation needs to be treated aggressively. Therefore, a potent (class 2 or 3) corticosteroid may need to be used initially to "put out the fire" in children with a moderate-to-severe flare involving the trunk and/or extremities, followed by tapering to a low to midpotency agent once the inflammation has been controlled.

For the face and folds, however, only low to midpotency corticosteroids should be used, and for facial disease, especially around the eyes, the TCIs — pimecrolimus (Elidel, Valeant) or tacrolimus (Protopic, Astellas) — are especially helpful as a steroid-sparing alternative, says Dr. Mancini, professor of pediatrics and dermatology, Northwestern University Feinberg School of Medicine, Chicago.

Dr. Friedlander, professor of clinical pediatrics and medicine, University of California, San Diego, concurs on the role of TCIs, but she adds that topical corticosteroids should still be used as the first line of defense to calm inflammation before starting the TCI.

"Using a TCI on flared skin causes significant stinging that will make the child miserable," she says.

TCI use in children younger than age 2 remain off-label after a Food and Drug Administration Pediatric Advisory Committee met in May 2011 to revisit the issue of TCI safety. The group reviewed five observational studies published since January 2005 that looked for evidence of an association between TCI use and various malignancies and also considered data from the FDA-mandated patient registries for the two TCI products, which had enrolled nearly 12,000 to date. That patient registries showed no increased signal for malignancy above that seen in the SEER database, although one published paper showed a possible increased malignancy signal, which was only for T-cell lymphoma and only in association with tacrolimus (Hui RL, Lide W, Chan J, et al. Ann Pharmacother. 2009;43(12):1956-1963). The group acknowledge the latter observation may be explained by potential study biases and was open to reviewing the safety issue again in the future, but it concluded that the current warnings and contraindications in the TCI labeling and medication guide are appropriate.

"We are hoping these drugs will be approved for use in younger children in the future. For now, we are using the TCIs off-label when we feel it is appropriate and making the families aware of the black box warning, but not focusing on it," Dr. Friedlander says.

Restoring barrier function

Understanding that an abnormal skin barrier plays a role in AD pathogenesis has focused interest on the use of barrier repair products in disease management. Dr. Friedlander says there is good evidence demonstrating the efficacy of these products as an effective tool for treating persistent mild disease.

Dr. Mancini agrees that barrier repair agents can be a useful alternative for treating early mild-to-moderate flares and as a standalone modality in maintenance care to prevent flares. For more severe disease, a barrier repair product can be used in combination with anti-inflammatory agents, he says.

"Used alone, barrier repair agents may not be sufficient to control more severe active disease, but they do offer an option for children whose parents are worried about using steroids and TCIs," he says.

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