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Untapped potential remains in eczema, psoriasis management
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Each year, children and adolescents require more than 12 million office visits related to rashes and other skin conditions, with 68% of these visits handled by primary care providers. Chief among these concerns are a variety of inflammatory skin disorders, including atopic dermatitis – also known as eczema – and psoriasis.
According to the National Eczema Association, the prevalence of childhood AD in the United States is 10.7% nationwide and could be as high as 18% in individual states, with approximately one out of three patients exhibiting moderate to severe disease.
Photo courtesy of Eastern Virginia Medical School
Although less prevalent than AD – affecting approximately 1% of the pediatric population according to the American Academy of Dermatology – psoriasis can significantly impact a child’s quality of life and is associated with several comorbidities, including cardiovascular disease.
Most children with AD and psoriasis exhibit mild disease that could be managed by their pediatrician or primary care provider; however, a recent study by Saavedra and colleagues in the Journal of Pediatrics found that providers instead referred 85% of these patients to dermatologists following initial care.
As parents of patients with these skin conditions regularly turn to their pediatricians for additional guidance, the pediatrician plays a critical role in the management of these chronic diseases, providing maintenance care following specialist evaluation and managing mild or episodic flare-ups.
To determine how primary care providers could improve diagnosis and management of AD and psoriasis in their practices, Infectious Diseases in Children spoke with several pediatric dermatology experts regarding practice changes that have markedly altered the way pediatricians counsel patients and their families and approach treatment.
Spotted in the primary care office
Among the myriad skin concerns that present themselves to pediatricians, AD is one of the most consistent. Primarily affecting children, AD is a chronic, relapsing, and frequently intensely pruritic inflammatory skin condition; per a national epidemiologic study by Shaw et al in the Journal of Investigative Dermatology, AD occurs in the majority (65%) of affected children within the first year of life.
AD is commonly observed on the cheeks, scalp, trunk and extremities of infants, the flexural areas – including armpits, elbows and groin – among children, and predominantly in the hands and feet of adolescents. The persistent itch commonly associated with AD is often the most challenging symptom for children and is usually the one that brings parents to the pediatric office for relief. However, before beginning treatment, it is essential that primary care providers exclude other possible diagnoses, as too often AD can be a ‘red herring’ in a case of pediatric psoriasis.
“Pediatric psoriasis is often difficult to diagnose in childhood, as it shares many characteristics with the more commonly seen eczematous disorders, such as infantile seborrheic dermatitis and atopic dermatitis,” Sheila Fallon Friedlander, MD, director of the Dermatology Fellowship Training Program at Rady Children’s Hospital, told Infectious Diseases in Children. “The facial and anogenital areas are more severely and commonly involved in children, and many a case of infantile psoriasis is initially thought to be ‘refractory diaper dermatitis.’”
Although less widespread than AD, pediatric psoriasis can present similarly, manifesting on the face and flexural regions as well as in the diaper area in the form of psoriatic lesions during infancy. In a study by Tollefson et al in the Journal of the American Academy of Dermatology, chronic plaque psoriasis was the most common type (73.7%) among children, followed by guttate psoriasis (14%), generally presenting on the extremities and the scalp.
“In many ways, psoriasis can be quite similar in both children and adults in that lesions can develop on all parts of the body, and can be associated with itchiness, burning, pain and scaling,” Abby Van Voorhees, MD, chair of the medical board at the National Psoriasis Foundation, said in an interview. “However, in children, psoriasis more commonly affects the face, and in very small children, it can also affect the groin.”
Hesitation hindering timely treatment
Potential misdiagnosis of AD or psoriasis can be especially concerning among children, as delaying effective treatment could worsen disease symptoms, while incorrect treatment runs the risk of unnecessary adverse reactions.
To combat common mistakes in the primary care office, in 2013 the American Academy of Dermatology released updated evidence-based guidelines for the assessment, diagnosis and monitoring of AD. The guidelines also discussed measurements for disease severity and quality of life, as well as associated conditions that commonly affect patients with AD.
The guidelines recommended that physicians ask their patients general questions about itch, sleep, impact on daily activity, as well as persistence of the disease. While these resources are widely available to primary care providers, the question remains whether it is a lack of ‘hands on’ experience that may impede a pediatrician’s ability to manage these conditions.
“Unfortunately, the education for pediatricians with certain interests in atopic dermatitis is poor. There are simply not centers where pediatricians can observe pediatric dermatologists in clinical rotations, and other providers just do not get that exposure at all,” Amy S. Paller, MD, chair of the department of dermatology at Northwestern University Feinberg School of Medicine, told Infectious Diseases in Children. “Pediatric psoriasis can be particularly difficult to diagnose in primary care, namely because it can look atypical for how psoriasis usually presents, and because there is even less exposure to psoriasis in training since its much less common in children.”
While providers are encouraged to refer to a specialist if the patient’s condition exceeds their experience or ability to manage, it is crucial that pediatricians have already examined all available options before referring the patient and delaying possible treatment. Among patients with mild-to-moderate AD, interventions such as intermittent corticosteroids and topical calcineurin inhibitors should be used prior to referring to a specialist.
“A lack of education coupled with a fear of topical steroids can make some providers uncomfortable in treating these patients,” Paller said. “I have seen many children treated with over-the-counter hydrocortisone, which will only help in the mildest of cases. I have also treated patients who were put on a topical steroid, but told only to use for it 3 days, which again is not going to help much. I think there remains a lot of ignorance out there about how to appropriately treat these conditions.”
Tool of last resort
Between 1997 and 2004, there were an estimated 7.4 million visits to office-based physicians and hospital outpatient departments by children aged less than 18 years for the treatment of AD, according to a study by Horii and colleagues published in Pediatrics.
However, with visits for pediatric AD peaking at 1.7 million in 2003, researchers also found that recommended first-line treatments were prescribed in a minority of visits: topical corticosteroids were prescribed in only 34% of visits from 1997 to 2000, decreasing to 25% between 2001 and 2004.
With rising numbers of AD cases and a lack of medical subspecialists to stem the tide, pediatricians are likely to see many more cases funneling into primary care offices, where misperceptions and concerns regarding steroid use need to be addressed from both sides.
“I think most pediatricians will first try to treat these conditions within their comfort zone, but the issue that often comes up is that there are many more treatments available in terms of topical steroids, which have limitations in terms of efficacy, safety or both,” Jonathan I. Silverberg, MD, PhD, MPH, assistant professor in dermatology, medical social sciences and preventive medicine at the Northwestern University Feinberg School of Medicine in Chicago, said in an interview.
“This poses a problem because many pediatricians are not comfortable using mid-potency or super-potent topical steroids, due to concerns of atrophy or other side effects related to chronic topical steroid use,” he said.
Although topical corticosteroids form the backbone of treatment for many inflammatory skin conditions, ‘steroid phobia’ persists among parents due, in part, to the tendency for the public to group steroids together, regardless of dissimilar potential for adverse effects. Additionally, misinformation regarding the difference between topical and systemic corticosteroids and their associated adverse events can contribute to poor treatment adherence, increasing the risk of poor clinical response and ultimate treatment failure.
“While we know that steroids work, they carry many side effects, as well as the phobia that parents and children have about their use,” Emma Guttman, MD, director of the Center of Excellence in Eczema at The Mount Sinai Hospital, told Infectious Diseases in Children.
“We need safe medications that are not steroids because, at the moment, children with severe eczema are being undertreated by pediatricians, using hydrocortisone 1% or hydrocortisone 2.5%. I think each specialty should do what they do best; primary care providers can treat children with mild disease, but if the disease is unresponsive, they need to refer to dermatologists.”
Connections to obesity
While recent studies have demonstrated that a high BMI at an early age is associated with the development of psoriasis later in life, researchers have been unable to determine how the two conditions are linked or whether one condition drives the other.
A study by Lónnberg and colleagues in JAMA Dermatology, examining data from 33,588 Danish twins, indicated that psoriasis was closely associated with type 2 diabetes and obesity, yet could not infer causation of one condition from another in their findings. While researchers posited that one condition could lead to behaviors that predisposed patients to the other conditions, the association of these three conditions most likely had a common genetic cause.
“We have known for a long time that psoriasis can be very common in children who are heavy, with some speculating that obesity may be that primary driver, particularly due to carrying that extra adipose tissue,” Van Voorhees said. “While this is not absolutely confirmed yet, it speaks to the need for working with children on their weight management, especially when they develop psoriasis.”
Additionally, a paper by the National Psoriasis Foundation Medical Board, published in the Journal of the American Academy of Dermatology, asserted that obese patients with psoriasis were at increased risk of adverse effects from medications and less likely to respond to systemic therapies vs. patients who were not overweight.
“I think it has been increasingly recognized that psoriasis fits in with metabolic syndromes, such as obesity, high cholesterol and type 2 diabetes,” Jenny Murase, MD, FAAD, assistant clinical professor of dermatology at University of California, San Francisco, told Infectious Diseases in Children. “If you have psoriasis, you are at increased risk for cardiovascular disease, including heart attack, stroke or peripheral vascular disease. As such, it is important for patients who are diagnosed with pediatric psoriasis to get their cholesterol checked each year, and make sure they do not fall within this metabolic syndrome.”
As children with obesity are already more prone to a range of health problems, it falls to their primary care providers to ensure that appropriate interventions are underway to mitigate the long-term effects, which may require additional office visits and the involvement of a registered dietitian or behavioral medicine provider.
“We don’t expect to see heart attacks and strokes in the pediatric age group, but the risk factors are already there early on for children who have psoriasis,” Silverberg said. “Even within the pediatric realm, we are seeing increased BMI, risks associated with high blood pressure, and significantly higher insulin resistance in patients with psoriasis than those without. When we consider the long-term health sequelae for patients with psoriasis with these associated comorbidities, its very concerning for the cardiovascular risk and cardiovascular comorbidities later in life.”
Solutions in primary care
There have been two major recent breakthroughs for the treatment of mild-to-moderate AD and psoriasis, according to Friedlander: crisaborole, a non-steroidal topical anti-inflammatory PDE-4 inhibitor, and dupilumab, a human monoclonal antibody against interleukin-4 receptor alpha.
In a pair of phase 3 multicenter, double-blind, vehicle-controlled studies published earlier this year, crisaborole topical ointment, 2%, (Anacor Pharmaceuticals) was found to be safe and effective for patients aged older than 2 years with mild-to-moderate AD.
“Multiple studies have documented the efficacy and safety of this drug, including pediatric pharmacokinetic studies, which have shown negligible absorption,” Friedlander said. “The NDA approval for this drug is expected to lead to release and availability in January of 2017. Pediatric and adult dermatologists alike have celebrated this addition of the first non-steroidal topical approach to the treatment of eczema in the last decade.”
Similarly, in two randomized, placebo-controlled, phase 3 trials of adults with moderate-to-severe AD, dupilumab (Regeneron Pharmaceuticals) combined with topical corticosteroids was found to significantly improve measures of overall disease severity when compared with topical corticosteroids alone.
“Dupilumab inhibits the interceptor for both interleukin 4 and interleukin 13 signaling pathways, which are thought to be the drivers of TH-2 cytokine activation,” Paller said in an interview. “By hitting the receptor, you hit both, which can produce some very nice results and even more so when coupled with topical steroids. I think this will be an exciting opportunity for treatment of adults and then children in time.”
Until these agents are available to children, however, pediatricians should continue to focus on maintaining disease control and prolonged periods between flares. Parents of children confronting these diseases that can be disfiguring and may be lifelong afflictions will often seek additional advice on maintenance strategies from their pediatricians, and providers should be prepared with an action plan for these families, including recommendations on bathing, moisturizers and antihistamines.
“Children who have eczema carry more bacteria on their skin than children without skin diseases, so bleach baths can be highly effective as a very conservative way to minimize the need for antibiotics,” Van Voorhees said.
As a simple and inexpensive maintenance therapy, bleach baths have been commonly recommended to decrease bacterial infections and reduce symptom severity. However, Friedlander noted that it is important for pediatricians to counsel parents about the need to properly dilute these bleach baths, as full-strength bleach is extremely dangerous.
“I have had patients who use no topical steroids and simply moisturize often in order to keep their eczema at bay in between bleach baths,” Murase told Infectious Diseases in Children. “I am less inclined to recommend coconut oil for moisturizing due to the allergen risk; however, I would recommend Cetaphil, Soravil or Vanicream as these are low-allergen moisturizers.”
Additionally, when selecting moisturizers, Guttman recommended that pediatricians encourage parents to pick products with the lowest amount of preservatives and no fragrances: “The simpler you go, the better.”
As with other chronic illnesses and medical conditions seen in the primary care office, it is important that psoriasis and AD are diagnosed and treated early to lessen the overall impact on both the child and their parents. Given the increasing prevalence of both psoriasis and AD, it is essential that primary care providers learn about the recent changes in management and treatment for these common dermatoses they will encounter in their practice.
With additional education regarding these two increasingly common conditions, pediatricians may be able to streamline treatment, determining in a timely and accurate fashion which patients are within their ability to treat and which might be better referred out for care by a specialist. – by Kate Sherrer and Bob Stott
- References:
- Bremmer S, et al. J Am Acad Dermatol. 2010; doi: 10.1016/j.jaad.2009.09.053.
- Horii KA et al. Pediatrics. 2007; doi: 10.1542/peds.2007-0289
- Krowchuk DP et al. Pediatr Dermatol. 1994; doi: 10.1111/j.1525-1470.1994.tb00586.
- Lonnberg AS et al. JAMA Dermatol. 2016; doi:10.1001/jamadermatol.2015.6262.
- Saavedra JM, et al. J Pediatr. 2013; doi: 10.1016/j.jpeds.2013.06.073.
- Shaw TE. J Invest Dermatol. 2011; doi: 10.1038/jid.2010.251.5.
- Tollefson MM, et al. J Am Acad Dermatol. 2010; doi: 10.1016/j.jaad.2009.07.029.
- For more information:
- Sheila Fallon Friedlander, MD, can be reached at Rady Children’s Hospital, 2010 Frost St, Ste 602, San Diego, CA 92123; email: sfriedlander@rchsd.org.
- Emma Guttman, MD, PhD, can be reached at Mount Sinai Health System, 555 W 57th St, New York, NY 10019; email: eguttman@mail.rockefeller.edu.
- Jenny E. Murase, MD, FAAD, can be reached at Palo Alto Medical Foundation, 701 E El Camino Real, Mountain View, CA 94040; email: jemurase@gmail.com.
- Amy S. Paller, MD, can be reached at Northwestern University Feinberg School of Medicine, NMH/Arkes Family Pavilion Ste 1600, 676 N Saint Clair, Chicago, IL 60611; email: amy.paller@nm.org.
- Jonathan I. Silverberg, MD, PhD, MPH, can be reached at Northwestern University Feinberg School of Medicine, NMH/Arkes Family Pavilion Ste 1600, 676 N Saint Clair, Chicago, IL 60611; email: jonathanisilverberg@gmail.com.
- Abby Van Voorhees, MD, can be reached at Eastern Virginia Medical School, 721 Fairfax Ave, Ste 200, Norfolk, VA 23507; email: vanvooas@evms.edu.
Disclosure: Friedlander, Guttman, Murase, Paller, Silverberg and Van Voorhees report no relevant financial disclosures.