Atopic Dermatitis

Key clinical point: Salivary cortisol levels were neither associated with the severity of atopic dermatitis (AD) nor could measure the stress associated with it.

Major finding: Salivary cortisol levels increased in both symptomatic and asymptomatic patients, but the levels were significantly lower in symptomatic vs. asymptomatic patients (P = .011) and those with severe vs. moderate and mild disease (P = .042). However, the severity of perceived stress could neither be measured by cortisol levels nor by disease severity.

Study details: Findings are from a prospective study including symptomatic (n = 42) and asymptomatic (n =               42) patients with AD.

Disclosures: The study did not report any source of funding. The authors declared no conflicts of interest.

Source: Meštrović-Štefekov  J et al. Dermatitis. 2022 (Jan 25). Doi: 10.1097/DER.0000000000000834.

Key clinical point: Salivary cortisol levels were neither associated with the severity of atopic dermatitis (AD) nor could measure the stress associated with it.

Major finding: Salivary cortisol levels increased in both symptomatic and asymptomatic patients, but the levels were significantly lower in symptomatic vs. asymptomatic patients (P = .011) and those with severe vs. moderate and mild disease (P = .042). However, the severity of perceived stress could neither be measured by cortisol levels nor by disease severity.

Study details: Findings are from a prospective study including symptomatic (n = 42) and asymptomatic (n =               42) patients with AD.

Disclosures: The study did not report any source of funding. The authors declared no conflicts of interest.

Source: Meštrović-Štefekov  J et al. Dermatitis. 2022 (Jan 25). Doi: 10.1097/DER.0000000000000834.

Key clinical point: Salivary cortisol levels were neither associated with the severity of atopic dermatitis (AD) nor could measure the stress associated with it.

Major finding: Salivary cortisol levels increased in both symptomatic and asymptomatic patients, but the levels were significantly lower in symptomatic vs. asymptomatic patients (P = .011) and those with severe vs. moderate and mild disease (P = .042). However, the severity of perceived stress could neither be measured by cortisol levels nor by disease severity.

Study details: Findings are from a prospective study including symptomatic (n = 42) and asymptomatic (n =               42) patients with AD.

Disclosures: The study did not report any source of funding. The authors declared no conflicts of interest.

Source: Meštrović-Štefekov  J et al. Dermatitis. 2022 (Jan 25). Doi: 10.1097/DER.0000000000000834.

Key clinical point: Moderate-to-severe lower respiratory tract infection (LRTI) before 18 months of age is a significant risk factor for developing atopic dermatitis (AD) in later childhood.

Major finding: The group of infants with moderate-severe vs. no or mild LRTI had significantly higher rates of AD at age 3 years (P = .001) and 5 years (P = .006) with moderate-to-severe vs. no LRTI in the first 18 months of life being significantly associated with increased odds of AD in later childhood (odds ratio [OR] 2.19; P < .001) independent of both-parent history of asthma and both-parent genetic predisposition.

Study details: Findings are from the Canadian Healthy Infant Longitudinal Development (CHILD) Cohort Study, comprising a longitudinal birth cohort of 3,272 parents and infants recruited during pregnancy and followed from birth onwards.

Disclosures: This study was funded by the Canadian Institutes of Health Research and Allergy, Genes, and Environment Network of Centers of Excellence. The authors declared no conflicts of interest.

Source: Medeleanu M et al. J Allergy Clin Immunol. 2022 (Jan 16). Doi: 10.1016/j.jacig.2021.12.005

Key clinical point: Moderate-to-severe lower respiratory tract infection (LRTI) before 18 months of age is a significant risk factor for developing atopic dermatitis (AD) in later childhood.

Major finding: The group of infants with moderate-severe vs. no or mild LRTI had significantly higher rates of AD at age 3 years (P = .001) and 5 years (P = .006) with moderate-to-severe vs. no LRTI in the first 18 months of life being significantly associated with increased odds of AD in later childhood (odds ratio [OR] 2.19; P < .001) independent of both-parent history of asthma and both-parent genetic predisposition.

Study details: Findings are from the Canadian Healthy Infant Longitudinal Development (CHILD) Cohort Study, comprising a longitudinal birth cohort of 3,272 parents and infants recruited during pregnancy and followed from birth onwards.

Disclosures: This study was funded by the Canadian Institutes of Health Research and Allergy, Genes, and Environment Network of Centers of Excellence. The authors declared no conflicts of interest.

Source: Medeleanu M et al. J Allergy Clin Immunol. 2022 (Jan 16). Doi: 10.1016/j.jacig.2021.12.005

Key clinical point: Moderate-to-severe lower respiratory tract infection (LRTI) before 18 months of age is a significant risk factor for developing atopic dermatitis (AD) in later childhood.

Major finding: The group of infants with moderate-severe vs. no or mild LRTI had significantly higher rates of AD at age 3 years (P = .001) and 5 years (P = .006) with moderate-to-severe vs. no LRTI in the first 18 months of life being significantly associated with increased odds of AD in later childhood (odds ratio [OR] 2.19; P < .001) independent of both-parent history of asthma and both-parent genetic predisposition.

Study details: Findings are from the Canadian Healthy Infant Longitudinal Development (CHILD) Cohort Study, comprising a longitudinal birth cohort of 3,272 parents and infants recruited during pregnancy and followed from birth onwards.

Disclosures: This study was funded by the Canadian Institutes of Health Research and Allergy, Genes, and Environment Network of Centers of Excellence. The authors declared no conflicts of interest.

Source: Medeleanu M et al. J Allergy Clin Immunol. 2022 (Jan 16). Doi: 10.1016/j.jacig.2021.12.005

Key clinical point: Infections in early life increase the risk of developing atopic dermatitis (AD) later in infancy and early childhood.

Major finding: Prior to AD diagnosis, all infections including skin infection up to 2 years of age were more frequent in patients who subsequently developed AD vs. healthy controls (P < .001), with a significant association observed between having any infection before AD diagnosis and subsequent development of AD (adjusted odds ratio, 1.40; P < .001), which persisted up to 2 years of age.

Study details: Findings are from a population-based, nationwide case-control study including 5,454 patients (mean age 2.6±2.9 years) with AD matched with 16,362 healthy controls without AD.

Disclosures: This study is supported by the Ministry of Science and Technology and Taichung Veterans General Hospital. The authors declared no conflicts of interest.

Source: Lin T-L et al. J Eur Acad Dermatol Venereol. 2022 (Jan 9). Doi: 10.1111/jdv.17908

Key clinical point: Infections in early life increase the risk of developing atopic dermatitis (AD) later in infancy and early childhood.

Major finding: Prior to AD diagnosis, all infections including skin infection up to 2 years of age were more frequent in patients who subsequently developed AD vs. healthy controls (P < .001), with a significant association observed between having any infection before AD diagnosis and subsequent development of AD (adjusted odds ratio, 1.40; P < .001), which persisted up to 2 years of age.

Study details: Findings are from a population-based, nationwide case-control study including 5,454 patients (mean age 2.6±2.9 years) with AD matched with 16,362 healthy controls without AD.

Disclosures: This study is supported by the Ministry of Science and Technology and Taichung Veterans General Hospital. The authors declared no conflicts of interest.

Source: Lin T-L et al. J Eur Acad Dermatol Venereol. 2022 (Jan 9). Doi: 10.1111/jdv.17908

Key clinical point: Infections in early life increase the risk of developing atopic dermatitis (AD) later in infancy and early childhood.

Major finding: Prior to AD diagnosis, all infections including skin infection up to 2 years of age were more frequent in patients who subsequently developed AD vs. healthy controls (P < .001), with a significant association observed between having any infection before AD diagnosis and subsequent development of AD (adjusted odds ratio, 1.40; P < .001), which persisted up to 2 years of age.

Study details: Findings are from a population-based, nationwide case-control study including 5,454 patients (mean age 2.6±2.9 years) with AD matched with 16,362 healthy controls without AD.

Disclosures: This study is supported by the Ministry of Science and Technology and Taichung Veterans General Hospital. The authors declared no conflicts of interest.

Source: Lin T-L et al. J Eur Acad Dermatol Venereol. 2022 (Jan 9). Doi: 10.1111/jdv.17908

Key clinical point: Atopic dermatitis (AD) is prevalent among young adults, with men being at increased odds of having AD in early life and decreased odds of having AD at adolescence and young adulthood.

Major finding: At 24 years, the 12-month prevalence of AD was 17.8%, with the prevalence being higher in women vs. men (20.5% vs. 14.8%; P < .0001). Men vs. women were more likely to have AD in the first year of life (odds ratio [OR] 1.31; 95% CI 1.10-1.56) but less likely to have AD at 24 years (OR 0.66; 95% CI 0.55-0.80).

Study details: This study included 3,055 individuals from the population-based BAMSE cohort, who were followed for 24 years after birth, and responded to a questionnaire regarding AD at the 24-year follow-up.

Disclosures: This study was funded by the European Research Council, Swedish Research Council, Åke Wiberg foundation, and other sources. Some of the authors declared serving as meeting experts or receiving consultancy fees and lecture fees from various sources.

Source: Johansson EK et al. J Eur Acad Dermatol Venereol. 2022 (Jan 15). Doi: 10.1111/jdv.17929

Key clinical point: Atopic dermatitis (AD) is prevalent among young adults, with men being at increased odds of having AD in early life and decreased odds of having AD at adolescence and young adulthood.

Major finding: At 24 years, the 12-month prevalence of AD was 17.8%, with the prevalence being higher in women vs. men (20.5% vs. 14.8%; P < .0001). Men vs. women were more likely to have AD in the first year of life (odds ratio [OR] 1.31; 95% CI 1.10-1.56) but less likely to have AD at 24 years (OR 0.66; 95% CI 0.55-0.80).

Study details: This study included 3,055 individuals from the population-based BAMSE cohort, who were followed for 24 years after birth, and responded to a questionnaire regarding AD at the 24-year follow-up.

Disclosures: This study was funded by the European Research Council, Swedish Research Council, Åke Wiberg foundation, and other sources. Some of the authors declared serving as meeting experts or receiving consultancy fees and lecture fees from various sources.

Source: Johansson EK et al. J Eur Acad Dermatol Venereol. 2022 (Jan 15). Doi: 10.1111/jdv.17929

Key clinical point: Atopic dermatitis (AD) is prevalent among young adults, with men being at increased odds of having AD in early life and decreased odds of having AD at adolescence and young adulthood.

Major finding: At 24 years, the 12-month prevalence of AD was 17.8%, with the prevalence being higher in women vs. men (20.5% vs. 14.8%; P < .0001). Men vs. women were more likely to have AD in the first year of life (odds ratio [OR] 1.31; 95% CI 1.10-1.56) but less likely to have AD at 24 years (OR 0.66; 95% CI 0.55-0.80).

Study details: This study included 3,055 individuals from the population-based BAMSE cohort, who were followed for 24 years after birth, and responded to a questionnaire regarding AD at the 24-year follow-up.

Disclosures: This study was funded by the European Research Council, Swedish Research Council, Åke Wiberg foundation, and other sources. Some of the authors declared serving as meeting experts or receiving consultancy fees and lecture fees from various sources.

Source: Johansson EK et al. J Eur Acad Dermatol Venereol. 2022 (Jan 15). Doi: 10.1111/jdv.17929

Key clinical point: Children with inadequately controlled moderate-to-severe atopic dermatitis (AD) presented with a high disease burden characterized by itch, impaired quality of life (QoL), and disturbed sleep, which may be attributed to lower use of systemic therapies.

Major finding: Most of the children were receiving nonsystemic medications (77.2%) and reported a mean Eczema Area and Severity Index of 14.4 and Patient-Oriented Eczema Measure score of 15.6. Patients aged 6 to <12 years reported an itch score of 4.9; infants (0-3 years) and children (4 to <12 years) reported QoL scores of 10.3 and 10.8, respectively, and 31% of patients reported disturbed sleep because of AD.

Study details: Findings are based on interim baseline data from an ongoing, longitudinal study including 732 children aged <12 years with moderate-to-severe AD.

Disclosures: This study was funded by Sanofi and Regeneron Pharmaceuticals. The authors declared serving as investigators, consultants, speakers, and advisory board members or receiving research grants and honoraria from various sources. Some authors declared being employees or stockholders of Sanofi Genzyme or Regeneron Pharmaceuticals.

Source: Paller AS et al. J Am Acad Dermatol. 2022 (Jan 23). Doi: 10.1016/j.jaad.2022.01.018

Key clinical point: Children with inadequately controlled moderate-to-severe atopic dermatitis (AD) presented with a high disease burden characterized by itch, impaired quality of life (QoL), and disturbed sleep, which may be attributed to lower use of systemic therapies.

Major finding: Most of the children were receiving nonsystemic medications (77.2%) and reported a mean Eczema Area and Severity Index of 14.4 and Patient-Oriented Eczema Measure score of 15.6. Patients aged 6 to <12 years reported an itch score of 4.9; infants (0-3 years) and children (4 to <12 years) reported QoL scores of 10.3 and 10.8, respectively, and 31% of patients reported disturbed sleep because of AD.

Study details: Findings are based on interim baseline data from an ongoing, longitudinal study including 732 children aged <12 years with moderate-to-severe AD.

Disclosures: This study was funded by Sanofi and Regeneron Pharmaceuticals. The authors declared serving as investigators, consultants, speakers, and advisory board members or receiving research grants and honoraria from various sources. Some authors declared being employees or stockholders of Sanofi Genzyme or Regeneron Pharmaceuticals.

Source: Paller AS et al. J Am Acad Dermatol. 2022 (Jan 23). Doi: 10.1016/j.jaad.2022.01.018

Key clinical point: Children with inadequately controlled moderate-to-severe atopic dermatitis (AD) presented with a high disease burden characterized by itch, impaired quality of life (QoL), and disturbed sleep, which may be attributed to lower use of systemic therapies.

Major finding: Most of the children were receiving nonsystemic medications (77.2%) and reported a mean Eczema Area and Severity Index of 14.4 and Patient-Oriented Eczema Measure score of 15.6. Patients aged 6 to <12 years reported an itch score of 4.9; infants (0-3 years) and children (4 to <12 years) reported QoL scores of 10.3 and 10.8, respectively, and 31% of patients reported disturbed sleep because of AD.

Study details: Findings are based on interim baseline data from an ongoing, longitudinal study including 732 children aged <12 years with moderate-to-severe AD.

Disclosures: This study was funded by Sanofi and Regeneron Pharmaceuticals. The authors declared serving as investigators, consultants, speakers, and advisory board members or receiving research grants and honoraria from various sources. Some authors declared being employees or stockholders of Sanofi Genzyme or Regeneron Pharmaceuticals.

Source: Paller AS et al. J Am Acad Dermatol. 2022 (Jan 23). Doi: 10.1016/j.jaad.2022.01.018

Key clinical point: Adults with atopic dermatitis (AD) who received COVID-19 vaccination did not show a higher risk for any assessed adverse events (AE) than those without AD; however, a minimal risk persisted among patients with a 1-year history of immunosuppressive or immunomodulatory therapy.

Major finding: The risk for 1-day immediate AEs, AEs at 30/60/90-day follow-up, and breakthrough infections was similar between vaccinated adults with vs. without AD; however, those who had a 1-year history of immunosuppressant or immunomodulatory therapy were at a higher risk for all-cause hospitalization at 30 days (adjusted hazard ratio [aHR] 2.14; 95% CI 1.27-3.59), 60 days (aHR 1.77; 95% CI 1.22-2.56), and 90 days (aHR 1.68; 95% CI 1.25-2.27) after vaccination.

Study details: Findings are from a retrospective cohort study including 1,262,306 vaccinated adults, of which 1.2% of adults had a history of AD.

Disclosures: This study did not report any source of funding. Some of the authors declared serving as consultants, honoraria speakers, and receiving research funding from several sources.

Source: Pakhchanian H et al. Br J Dermatol. 2022 (Jan 27). Doi: 10.1111/bjd.21038

Key clinical point: Adults with atopic dermatitis (AD) who received COVID-19 vaccination did not show a higher risk for any assessed adverse events (AE) than those without AD; however, a minimal risk persisted among patients with a 1-year history of immunosuppressive or immunomodulatory therapy.

Major finding: The risk for 1-day immediate AEs, AEs at 30/60/90-day follow-up, and breakthrough infections was similar between vaccinated adults with vs. without AD; however, those who had a 1-year history of immunosuppressant or immunomodulatory therapy were at a higher risk for all-cause hospitalization at 30 days (adjusted hazard ratio [aHR] 2.14; 95% CI 1.27-3.59), 60 days (aHR 1.77; 95% CI 1.22-2.56), and 90 days (aHR 1.68; 95% CI 1.25-2.27) after vaccination.

Study details: Findings are from a retrospective cohort study including 1,262,306 vaccinated adults, of which 1.2% of adults had a history of AD.

Disclosures: This study did not report any source of funding. Some of the authors declared serving as consultants, honoraria speakers, and receiving research funding from several sources.

Source: Pakhchanian H et al. Br J Dermatol. 2022 (Jan 27). Doi: 10.1111/bjd.21038

Key clinical point: Adults with atopic dermatitis (AD) who received COVID-19 vaccination did not show a higher risk for any assessed adverse events (AE) than those without AD; however, a minimal risk persisted among patients with a 1-year history of immunosuppressive or immunomodulatory therapy.

Major finding: The risk for 1-day immediate AEs, AEs at 30/60/90-day follow-up, and breakthrough infections was similar between vaccinated adults with vs. without AD; however, those who had a 1-year history of immunosuppressant or immunomodulatory therapy were at a higher risk for all-cause hospitalization at 30 days (adjusted hazard ratio [aHR] 2.14; 95% CI 1.27-3.59), 60 days (aHR 1.77; 95% CI 1.22-2.56), and 90 days (aHR 1.68; 95% CI 1.25-2.27) after vaccination.

Study details: Findings are from a retrospective cohort study including 1,262,306 vaccinated adults, of which 1.2% of adults had a history of AD.

Disclosures: This study did not report any source of funding. Some of the authors declared serving as consultants, honoraria speakers, and receiving research funding from several sources.

Source: Pakhchanian H et al. Br J Dermatol. 2022 (Jan 27). Doi: 10.1111/bjd.21038

Global climate change is hitting home for dermatologists, according to a recent survey in which the majority of participants said their patients are already being impacted.

Almost 80% of the 148 participants who responded to an electronic survey reported this belief.

The survey was designed and distributed to the membership of various dermatological organizations by Misha Rosenbach, MD, and coauthors. The results were published in the British Journal of Dermatology.

Asked also about specific types of climate-driven phenomena with a current – or future – impact on their patients, 80.1% reported that they believed that increased exposure to ultraviolet radiation (UVR) is impactful, or will be. Changes in temporal or geographic patterns of vector-borne illnesses were affirmed by 78.7%, and an increase in social displacement caused by extreme weather or other events was affirmed by 67.1% as having an impact on their patients currently or in the future.

Other phenomena affirmed by respondents as already having an impact or impacting patients in the future were an increased incidence of heat exposure or heat-related illness (58.2%); an increase in rates of inflammatory skin disease flares (43.2%); increased incidence of waterborne infections (42.5%); and increased rates of allergic contact dermatitis (29.5%).

The survey was sent to the membership of the American Society of Dermatologic Surgery, the Society for Pediatric Dermatology, the Society for Investigative Dermatology, and the American Academy of Dermatology’s Climate Change Expert Resource Group (ERG), among other organizations.

The study design and membership overlap made it impossible to calculate a response rate, the authors said, but they estimated it to be about 10%.

Almost all respondents were from the United States, and most (86.3%) practiced in an academic setting. The findings are similar to those of an online survey of members of the International Society of Dermatology (ISD), published in 2020, which found that 89% of 158 respondents believed climate change will impact the incidence of skin diseases in their area.

“Physicians, including dermatologists, are starting to understand the impact of the climate crisis on both their patients and themselves ... both through lived experiences and [issues raised] more in the scientific literature and in meetings,” Dr. Rosenbach, associate professor of dermatology at the University of Pennsylvania, Philadelphia, said in an interview.

A majority of participants in the U.S. survey agreed they have a responsibility to bring awareness of the health effects of climate change to patients (77.2%) and to policymakers (88.6%). (In the ISD survey, 88% said they believed that dermatologists should play an advocacy role in climate change-related issues).

Only a minority of respondents in the U.S. survey said that they would feel comfortable discussing climate change with their patients (37.2%). Almost one-third of the respondents said they would like to be better informed about climate change before doing so. And 81.8% said they would like to read more about the dermatological effects of climate change in scientific journals.

“There continues to be unfilled interest in education and advocacy regarding climate change, suggesting a ‘practice gap’ even among dermatologists,” Dr. Rosenbach and his colleagues wrote, noting opportunities for professional organizations and journals to provide more resources and “actionable items” regarding climate change.

Some dermatologists have been taking action, in the meantime, to reduce the carbon footprint of their practices and institutions. Reductions in facility energy consumption, and reductions in medical waste/optimization of recycling, were each reported by more than one-third of survey respondents.

And almost half indicated that their practice or institution had increased capacity for telemedicine or telecommuting in response to climate change. Only 8% said their practice or institution had divested from fossil fuel stocks and/or bonds.

“There are a lot of sustainability-in-medicine solutions that are actually cost-neutral or cost-saving for practices,” said Dr. Rosenbach, who is a founder and co-chair of the AAD’s ERG on Climate Change and Environmental Issues.

Research in dermatology is starting to quantify the environmental impact of some of these changes. In a research letter also published in the British Journal of Dermatology, researchers from Cardiff University and the department of dermatology at University Hospital of Wales, described how they determined that reusable surgical packs used for skin surgery are more sustainable than single-use packs because of their reduced cost and reduced greenhouse gas emissions.

Such single-site reports are “early feeders” into what will become a stream of larger studies quantifying the impact of measures taken in dermatology, Dr. Rosenbach said.

Across medicine, there is evidence that health care professionals are now seeing climate change as a threat to their patients. In a multinational survey published last year in The Lancet Planetary Health, 77% of 3,977 participants said that climate change will cause a moderate or great deal of harm for their patients.

Climate change will be discussed at the AAD’s annual meeting in late March in a session devoted to the topic, and as part of a broader session on controversies in dermatology.

Dr. Rosenbach and two of the five authors of the dermatology research letter are members of the AAD’s ERG on climate change, but in the publication they noted that they were not writing on behalf of the AAD. None of the authors reported any disclosures, and there was no funding source for the survey.

Global climate change is hitting home for dermatologists, according to a recent survey in which the majority of participants said their patients are already being impacted.

Almost 80% of the 148 participants who responded to an electronic survey reported this belief.

The survey was designed and distributed to the membership of various dermatological organizations by Misha Rosenbach, MD, and coauthors. The results were published in the British Journal of Dermatology.

Asked also about specific types of climate-driven phenomena with a current – or future – impact on their patients, 80.1% reported that they believed that increased exposure to ultraviolet radiation (UVR) is impactful, or will be. Changes in temporal or geographic patterns of vector-borne illnesses were affirmed by 78.7%, and an increase in social displacement caused by extreme weather or other events was affirmed by 67.1% as having an impact on their patients currently or in the future.

Other phenomena affirmed by respondents as already having an impact or impacting patients in the future were an increased incidence of heat exposure or heat-related illness (58.2%); an increase in rates of inflammatory skin disease flares (43.2%); increased incidence of waterborne infections (42.5%); and increased rates of allergic contact dermatitis (29.5%).

The survey was sent to the membership of the American Society of Dermatologic Surgery, the Society for Pediatric Dermatology, the Society for Investigative Dermatology, and the American Academy of Dermatology’s Climate Change Expert Resource Group (ERG), among other organizations.

The study design and membership overlap made it impossible to calculate a response rate, the authors said, but they estimated it to be about 10%.

Almost all respondents were from the United States, and most (86.3%) practiced in an academic setting. The findings are similar to those of an online survey of members of the International Society of Dermatology (ISD), published in 2020, which found that 89% of 158 respondents believed climate change will impact the incidence of skin diseases in their area.

“Physicians, including dermatologists, are starting to understand the impact of the climate crisis on both their patients and themselves ... both through lived experiences and [issues raised] more in the scientific literature and in meetings,” Dr. Rosenbach, associate professor of dermatology at the University of Pennsylvania, Philadelphia, said in an interview.

A majority of participants in the U.S. survey agreed they have a responsibility to bring awareness of the health effects of climate change to patients (77.2%) and to policymakers (88.6%). (In the ISD survey, 88% said they believed that dermatologists should play an advocacy role in climate change-related issues).

Only a minority of respondents in the U.S. survey said that they would feel comfortable discussing climate change with their patients (37.2%). Almost one-third of the respondents said they would like to be better informed about climate change before doing so. And 81.8% said they would like to read more about the dermatological effects of climate change in scientific journals.

“There continues to be unfilled interest in education and advocacy regarding climate change, suggesting a ‘practice gap’ even among dermatologists,” Dr. Rosenbach and his colleagues wrote, noting opportunities for professional organizations and journals to provide more resources and “actionable items” regarding climate change.

Some dermatologists have been taking action, in the meantime, to reduce the carbon footprint of their practices and institutions. Reductions in facility energy consumption, and reductions in medical waste/optimization of recycling, were each reported by more than one-third of survey respondents.

And almost half indicated that their practice or institution had increased capacity for telemedicine or telecommuting in response to climate change. Only 8% said their practice or institution had divested from fossil fuel stocks and/or bonds.

“There are a lot of sustainability-in-medicine solutions that are actually cost-neutral or cost-saving for practices,” said Dr. Rosenbach, who is a founder and co-chair of the AAD’s ERG on Climate Change and Environmental Issues.

Research in dermatology is starting to quantify the environmental impact of some of these changes. In a research letter also published in the British Journal of Dermatology, researchers from Cardiff University and the department of dermatology at University Hospital of Wales, described how they determined that reusable surgical packs used for skin surgery are more sustainable than single-use packs because of their reduced cost and reduced greenhouse gas emissions.

Such single-site reports are “early feeders” into what will become a stream of larger studies quantifying the impact of measures taken in dermatology, Dr. Rosenbach said.

Across medicine, there is evidence that health care professionals are now seeing climate change as a threat to their patients. In a multinational survey published last year in The Lancet Planetary Health, 77% of 3,977 participants said that climate change will cause a moderate or great deal of harm for their patients.

Climate change will be discussed at the AAD’s annual meeting in late March in a session devoted to the topic, and as part of a broader session on controversies in dermatology.

Dr. Rosenbach and two of the five authors of the dermatology research letter are members of the AAD’s ERG on climate change, but in the publication they noted that they were not writing on behalf of the AAD. None of the authors reported any disclosures, and there was no funding source for the survey.

Global climate change is hitting home for dermatologists, according to a recent survey in which the majority of participants said their patients are already being impacted.

Almost 80% of the 148 participants who responded to an electronic survey reported this belief.

The survey was designed and distributed to the membership of various dermatological organizations by Misha Rosenbach, MD, and coauthors. The results were published in the British Journal of Dermatology.

Asked also about specific types of climate-driven phenomena with a current – or future – impact on their patients, 80.1% reported that they believed that increased exposure to ultraviolet radiation (UVR) is impactful, or will be. Changes in temporal or geographic patterns of vector-borne illnesses were affirmed by 78.7%, and an increase in social displacement caused by extreme weather or other events was affirmed by 67.1% as having an impact on their patients currently or in the future.

Other phenomena affirmed by respondents as already having an impact or impacting patients in the future were an increased incidence of heat exposure or heat-related illness (58.2%); an increase in rates of inflammatory skin disease flares (43.2%); increased incidence of waterborne infections (42.5%); and increased rates of allergic contact dermatitis (29.5%).

The survey was sent to the membership of the American Society of Dermatologic Surgery, the Society for Pediatric Dermatology, the Society for Investigative Dermatology, and the American Academy of Dermatology’s Climate Change Expert Resource Group (ERG), among other organizations.

The study design and membership overlap made it impossible to calculate a response rate, the authors said, but they estimated it to be about 10%.

Almost all respondents were from the United States, and most (86.3%) practiced in an academic setting. The findings are similar to those of an online survey of members of the International Society of Dermatology (ISD), published in 2020, which found that 89% of 158 respondents believed climate change will impact the incidence of skin diseases in their area.

“Physicians, including dermatologists, are starting to understand the impact of the climate crisis on both their patients and themselves ... both through lived experiences and [issues raised] more in the scientific literature and in meetings,” Dr. Rosenbach, associate professor of dermatology at the University of Pennsylvania, Philadelphia, said in an interview.

A majority of participants in the U.S. survey agreed they have a responsibility to bring awareness of the health effects of climate change to patients (77.2%) and to policymakers (88.6%). (In the ISD survey, 88% said they believed that dermatologists should play an advocacy role in climate change-related issues).

Only a minority of respondents in the U.S. survey said that they would feel comfortable discussing climate change with their patients (37.2%). Almost one-third of the respondents said they would like to be better informed about climate change before doing so. And 81.8% said they would like to read more about the dermatological effects of climate change in scientific journals.

“There continues to be unfilled interest in education and advocacy regarding climate change, suggesting a ‘practice gap’ even among dermatologists,” Dr. Rosenbach and his colleagues wrote, noting opportunities for professional organizations and journals to provide more resources and “actionable items” regarding climate change.

Some dermatologists have been taking action, in the meantime, to reduce the carbon footprint of their practices and institutions. Reductions in facility energy consumption, and reductions in medical waste/optimization of recycling, were each reported by more than one-third of survey respondents.

And almost half indicated that their practice or institution had increased capacity for telemedicine or telecommuting in response to climate change. Only 8% said their practice or institution had divested from fossil fuel stocks and/or bonds.

“There are a lot of sustainability-in-medicine solutions that are actually cost-neutral or cost-saving for practices,” said Dr. Rosenbach, who is a founder and co-chair of the AAD’s ERG on Climate Change and Environmental Issues.

Research in dermatology is starting to quantify the environmental impact of some of these changes. In a research letter also published in the British Journal of Dermatology, researchers from Cardiff University and the department of dermatology at University Hospital of Wales, described how they determined that reusable surgical packs used for skin surgery are more sustainable than single-use packs because of their reduced cost and reduced greenhouse gas emissions.

Such single-site reports are “early feeders” into what will become a stream of larger studies quantifying the impact of measures taken in dermatology, Dr. Rosenbach said.

Across medicine, there is evidence that health care professionals are now seeing climate change as a threat to their patients. In a multinational survey published last year in The Lancet Planetary Health, 77% of 3,977 participants said that climate change will cause a moderate or great deal of harm for their patients.

Climate change will be discussed at the AAD’s annual meeting in late March in a session devoted to the topic, and as part of a broader session on controversies in dermatology.

Dr. Rosenbach and two of the five authors of the dermatology research letter are members of the AAD’s ERG on climate change, but in the publication they noted that they were not writing on behalf of the AAD. None of the authors reported any disclosures, and there was no funding source for the survey.

Current interventions to tackle Staphylococcus aureus in patients with atopic eczema have little impact on symptoms, based on data from a Cochrane Review of 41 studies published in Clinical and Experimental Allergy.

Eczema remains a huge disease burden worldwide, and colonization with S. aureus in eczema patients is common, but no standard intervention exists to relieve symptoms, wrote Nandini Banerjee, MD, of Addenbrooke’s Hospital, Cambridge, England. “While antibiotic treatment of clinically obvious infections such as cellulitis is beneficial, it is not clear whether antibiotic treatment of eczema influences eczema severity,” Dr. Banerjee noted.

The 41 studies included 1,753 participants and 10 treatment categories. Most of the studies were conducted in secondary care centers in Western Europe, North America, and the Far East. Twelve studies included children, four included only adults, 19 included children and adults, and in six studies, the participant age range was unclear. Among the studies with reported ages, the mean age ranged from 1.1 to 34.6 years. Eczema severity ranged from mild to severe, and treatment durations ranged from 10 minutes to 3 months.

The review presented comparisons of topical steroid/antibiotic combinations, oral antibiotics, and bleach baths. In 14 studies that compared topical steroid/antibiotic combinations to topical steroids alone, patients showed slightly greater global improvement in symptoms with the combination, but the impact on quality of life was not significantly different. Severe adverse events, including flare of dermatitis, worsening of eczema, and folliculitis, were reported by the patients who received the combination and the topical steroid–only patients. One study reported similar rates of antibiotic resistance in children treated with steroid only and with an antibiotic/steroid combination at 3 months’ follow-up.

In four studies, oral antibiotics “may make no difference in terms of good or excellent global improvement in infants and children at 14 to 28 days follow-up compared to placebo,” according to the review. The reviewers said that there was likely little or no difference in quality of life for infants and children given oral antibiotics, although they noted the low quality of evidence on this topic.

Five studies evaluated the impact of bleach baths on eczema patients with and without S. aureus infections. These studies showed no difference in global improvement measures compared with placebo and little or no difference in quality of life. Also, patients who underwent bleach baths compared with placebo patients reported similar adverse events of burning/stinging or dry skin at 2 months’ follow-up.

“Low-quality evidence, due to risk of bias, imprecise effect estimates, and heterogeneity, made pooling of results difficult,” Dr. Banerjee wrote. “Topical steroid/antibiotic combinations may be associated with possible small improvements in good or excellent signs/symptoms compared with topical steroid alone. High-quality trials evaluating efficacy, QOL, and antibiotic resistance are required,” she concluded.

In a commentary section after the review, Dr. Banerjee and colleagues noted that the United Kingdom’s NICE guidelines for managing atopic eczema in children younger than 12 years of age, published in March 2021, include evidence from the current updated Cochrane Review. The NICE guidelines emphasize that “in people who are not systemically unwell, clinicians should not routinely offer either a topical or oral antibiotic for secondary bacterial infection of eczema,” the Cochrane authors said. They added in their commentary that the use of antibiotics in cases of nonsevere infections can worsen eczema. Also, “the risk of antimicrobial resistance is high with topical antibiotics, and therefore extended doses of the same antibiotics should be avoided to prevent resistance,” they said. However, the authors acknowledged a role for antibiotics in certain situations. “In patients with systemic signs of infection such as cellulitis, systemic antibiotics have an important role in helping clear infection,” they noted.

Reasons for varying disease severity elude research

The current study is important because of the abundance of preclinical and clinical data that implicate S. aureus in atopic dermatitis pathogenesis, Brian Kim, MD, of the Icahn School of Medicine at Mount Sinai, New York, said in an interview.

Dr. Kim said that he was surprised by some of the study findings but not others. “On the one hand, I thought there would be data supporting antimicrobial therapy, albeit not strong support,” he said. “However, AD is a very complex disease, and understanding what a disease modifier does to it is hard to capture across studies of various different designs,” he said.

“The data supporting antimicrobial therapy for S. aureus in AD is not as clear as our clinical impressions may indicate,” said Dr. Kim. “We need to understand the relationship better, perhaps in particular subsets of patients,” he emphasized. In addition, “We need a better understanding of why some people are colonized with S. aureus, yet with little effect on AD itself, while others experience severe exacerbation of disease,” said Dr. Kim. Therefore, a key research question for future studies is whether the exacerbation is caused by the particular strain of the bug, the host susceptibility, or both, he said.

The review received no outside funding. Dr. Banerjee and Dr. Kim have disclosed that they had no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Current interventions to tackle Staphylococcus aureus in patients with atopic eczema have little impact on symptoms, based on data from a Cochrane Review of 41 studies published in Clinical and Experimental Allergy.

Eczema remains a huge disease burden worldwide, and colonization with S. aureus in eczema patients is common, but no standard intervention exists to relieve symptoms, wrote Nandini Banerjee, MD, of Addenbrooke’s Hospital, Cambridge, England. “While antibiotic treatment of clinically obvious infections such as cellulitis is beneficial, it is not clear whether antibiotic treatment of eczema influences eczema severity,” Dr. Banerjee noted.

The 41 studies included 1,753 participants and 10 treatment categories. Most of the studies were conducted in secondary care centers in Western Europe, North America, and the Far East. Twelve studies included children, four included only adults, 19 included children and adults, and in six studies, the participant age range was unclear. Among the studies with reported ages, the mean age ranged from 1.1 to 34.6 years. Eczema severity ranged from mild to severe, and treatment durations ranged from 10 minutes to 3 months.

The review presented comparisons of topical steroid/antibiotic combinations, oral antibiotics, and bleach baths. In 14 studies that compared topical steroid/antibiotic combinations to topical steroids alone, patients showed slightly greater global improvement in symptoms with the combination, but the impact on quality of life was not significantly different. Severe adverse events, including flare of dermatitis, worsening of eczema, and folliculitis, were reported by the patients who received the combination and the topical steroid–only patients. One study reported similar rates of antibiotic resistance in children treated with steroid only and with an antibiotic/steroid combination at 3 months’ follow-up.

In four studies, oral antibiotics “may make no difference in terms of good or excellent global improvement in infants and children at 14 to 28 days follow-up compared to placebo,” according to the review. The reviewers said that there was likely little or no difference in quality of life for infants and children given oral antibiotics, although they noted the low quality of evidence on this topic.

Five studies evaluated the impact of bleach baths on eczema patients with and without S. aureus infections. These studies showed no difference in global improvement measures compared with placebo and little or no difference in quality of life. Also, patients who underwent bleach baths compared with placebo patients reported similar adverse events of burning/stinging or dry skin at 2 months’ follow-up.

“Low-quality evidence, due to risk of bias, imprecise effect estimates, and heterogeneity, made pooling of results difficult,” Dr. Banerjee wrote. “Topical steroid/antibiotic combinations may be associated with possible small improvements in good or excellent signs/symptoms compared with topical steroid alone. High-quality trials evaluating efficacy, QOL, and antibiotic resistance are required,” she concluded.

In a commentary section after the review, Dr. Banerjee and colleagues noted that the United Kingdom’s NICE guidelines for managing atopic eczema in children younger than 12 years of age, published in March 2021, include evidence from the current updated Cochrane Review. The NICE guidelines emphasize that “in people who are not systemically unwell, clinicians should not routinely offer either a topical or oral antibiotic for secondary bacterial infection of eczema,” the Cochrane authors said. They added in their commentary that the use of antibiotics in cases of nonsevere infections can worsen eczema. Also, “the risk of antimicrobial resistance is high with topical antibiotics, and therefore extended doses of the same antibiotics should be avoided to prevent resistance,” they said. However, the authors acknowledged a role for antibiotics in certain situations. “In patients with systemic signs of infection such as cellulitis, systemic antibiotics have an important role in helping clear infection,” they noted.

Reasons for varying disease severity elude research

The current study is important because of the abundance of preclinical and clinical data that implicate S. aureus in atopic dermatitis pathogenesis, Brian Kim, MD, of the Icahn School of Medicine at Mount Sinai, New York, said in an interview.

Dr. Kim said that he was surprised by some of the study findings but not others. “On the one hand, I thought there would be data supporting antimicrobial therapy, albeit not strong support,” he said. “However, AD is a very complex disease, and understanding what a disease modifier does to it is hard to capture across studies of various different designs,” he said.

“The data supporting antimicrobial therapy for S. aureus in AD is not as clear as our clinical impressions may indicate,” said Dr. Kim. “We need to understand the relationship better, perhaps in particular subsets of patients,” he emphasized. In addition, “We need a better understanding of why some people are colonized with S. aureus, yet with little effect on AD itself, while others experience severe exacerbation of disease,” said Dr. Kim. Therefore, a key research question for future studies is whether the exacerbation is caused by the particular strain of the bug, the host susceptibility, or both, he said.

The review received no outside funding. Dr. Banerjee and Dr. Kim have disclosed that they had no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Current interventions to tackle Staphylococcus aureus in patients with atopic eczema have little impact on symptoms, based on data from a Cochrane Review of 41 studies published in Clinical and Experimental Allergy.

Eczema remains a huge disease burden worldwide, and colonization with S. aureus in eczema patients is common, but no standard intervention exists to relieve symptoms, wrote Nandini Banerjee, MD, of Addenbrooke’s Hospital, Cambridge, England. “While antibiotic treatment of clinically obvious infections such as cellulitis is beneficial, it is not clear whether antibiotic treatment of eczema influences eczema severity,” Dr. Banerjee noted.

The 41 studies included 1,753 participants and 10 treatment categories. Most of the studies were conducted in secondary care centers in Western Europe, North America, and the Far East. Twelve studies included children, four included only adults, 19 included children and adults, and in six studies, the participant age range was unclear. Among the studies with reported ages, the mean age ranged from 1.1 to 34.6 years. Eczema severity ranged from mild to severe, and treatment durations ranged from 10 minutes to 3 months.

The review presented comparisons of topical steroid/antibiotic combinations, oral antibiotics, and bleach baths. In 14 studies that compared topical steroid/antibiotic combinations to topical steroids alone, patients showed slightly greater global improvement in symptoms with the combination, but the impact on quality of life was not significantly different. Severe adverse events, including flare of dermatitis, worsening of eczema, and folliculitis, were reported by the patients who received the combination and the topical steroid–only patients. One study reported similar rates of antibiotic resistance in children treated with steroid only and with an antibiotic/steroid combination at 3 months’ follow-up.

In four studies, oral antibiotics “may make no difference in terms of good or excellent global improvement in infants and children at 14 to 28 days follow-up compared to placebo,” according to the review. The reviewers said that there was likely little or no difference in quality of life for infants and children given oral antibiotics, although they noted the low quality of evidence on this topic.

Five studies evaluated the impact of bleach baths on eczema patients with and without S. aureus infections. These studies showed no difference in global improvement measures compared with placebo and little or no difference in quality of life. Also, patients who underwent bleach baths compared with placebo patients reported similar adverse events of burning/stinging or dry skin at 2 months’ follow-up.

“Low-quality evidence, due to risk of bias, imprecise effect estimates, and heterogeneity, made pooling of results difficult,” Dr. Banerjee wrote. “Topical steroid/antibiotic combinations may be associated with possible small improvements in good or excellent signs/symptoms compared with topical steroid alone. High-quality trials evaluating efficacy, QOL, and antibiotic resistance are required,” she concluded.

In a commentary section after the review, Dr. Banerjee and colleagues noted that the United Kingdom’s NICE guidelines for managing atopic eczema in children younger than 12 years of age, published in March 2021, include evidence from the current updated Cochrane Review. The NICE guidelines emphasize that “in people who are not systemically unwell, clinicians should not routinely offer either a topical or oral antibiotic for secondary bacterial infection of eczema,” the Cochrane authors said. They added in their commentary that the use of antibiotics in cases of nonsevere infections can worsen eczema. Also, “the risk of antimicrobial resistance is high with topical antibiotics, and therefore extended doses of the same antibiotics should be avoided to prevent resistance,” they said. However, the authors acknowledged a role for antibiotics in certain situations. “In patients with systemic signs of infection such as cellulitis, systemic antibiotics have an important role in helping clear infection,” they noted.

Reasons for varying disease severity elude research

The current study is important because of the abundance of preclinical and clinical data that implicate S. aureus in atopic dermatitis pathogenesis, Brian Kim, MD, of the Icahn School of Medicine at Mount Sinai, New York, said in an interview.

Dr. Kim said that he was surprised by some of the study findings but not others. “On the one hand, I thought there would be data supporting antimicrobial therapy, albeit not strong support,” he said. “However, AD is a very complex disease, and understanding what a disease modifier does to it is hard to capture across studies of various different designs,” he said.

“The data supporting antimicrobial therapy for S. aureus in AD is not as clear as our clinical impressions may indicate,” said Dr. Kim. “We need to understand the relationship better, perhaps in particular subsets of patients,” he emphasized. In addition, “We need a better understanding of why some people are colonized with S. aureus, yet with little effect on AD itself, while others experience severe exacerbation of disease,” said Dr. Kim. Therefore, a key research question for future studies is whether the exacerbation is caused by the particular strain of the bug, the host susceptibility, or both, he said.

The review received no outside funding. Dr. Banerjee and Dr. Kim have disclosed that they had no relevant financial relationships.

A version of this article first appeared on Medscape.com.

The Food and Drug Administration has accepted a supplemental Biologics License Application (sBLA) for Priority Review of dupilumab to treat moderate to severe atopic dermatitis (AD) in children aged 6 months to 5 years, according to a statement from the manufacturers, Regeneron and Sanofi.

If approved, dupilumab would be the first biologic approved for children in this age group in the United States, according to the statement. The proposed indication is as add-on therapy for children with moderate to severe AD not adequately controlled with topical prescription therapies or for whom topical therapies are not advised. The FDA granted breakthrough therapy designation for dupilumab for the treatment of severe AD in children aged 6 months to 11 years in 2016.

Approximately 85%-95% of atopic dermatitis patients develop symptoms before 5 years of age, and these symptoms often continue into adulthood, with an increased risk of skin infections and a significant impact on quality of life, according to the statement.

The sBLA is based on data from a phase 3 pivotal study of 162 children aged 6 months to 5 years in which dupilumab was added to standard-of-care topical corticosteroids, presented in December 2021. In the study, dupilumab plus standard of care significantly improved skin clearance and reduced overall disease severity and itch at 16 weeks compared with standard of care alone. Overall, 28% of the children randomized to dupilumab achieved the primary endpoint of clear or almost-clear skin, compared with 4% with those on standard of care alone (P < .0001), according to the manufacturers. Patients in the dupilumab group received either 200 mg (for children weighing ≥ 5 to < 15 kg) or 300 mg (for children weighing ≥ 15 to < 30 kg) every 4 weeks. Safety results were similar to those seen with dupilumab for children aged 6 years and older.

Conjunctivitis and herpes infections were among the most common adverse events associated with dupilumab in the study, according to the statement.

The target action date for the FDA decision on this application is June 9, 2022.

The Food and Drug Administration has accepted a supplemental Biologics License Application (sBLA) for Priority Review of dupilumab to treat moderate to severe atopic dermatitis (AD) in children aged 6 months to 5 years, according to a statement from the manufacturers, Regeneron and Sanofi.

If approved, dupilumab would be the first biologic approved for children in this age group in the United States, according to the statement. The proposed indication is as add-on therapy for children with moderate to severe AD not adequately controlled with topical prescription therapies or for whom topical therapies are not advised. The FDA granted breakthrough therapy designation for dupilumab for the treatment of severe AD in children aged 6 months to 11 years in 2016.

Approximately 85%-95% of atopic dermatitis patients develop symptoms before 5 years of age, and these symptoms often continue into adulthood, with an increased risk of skin infections and a significant impact on quality of life, according to the statement.

The sBLA is based on data from a phase 3 pivotal study of 162 children aged 6 months to 5 years in which dupilumab was added to standard-of-care topical corticosteroids, presented in December 2021. In the study, dupilumab plus standard of care significantly improved skin clearance and reduced overall disease severity and itch at 16 weeks compared with standard of care alone. Overall, 28% of the children randomized to dupilumab achieved the primary endpoint of clear or almost-clear skin, compared with 4% with those on standard of care alone (P < .0001), according to the manufacturers. Patients in the dupilumab group received either 200 mg (for children weighing ≥ 5 to < 15 kg) or 300 mg (for children weighing ≥ 15 to < 30 kg) every 4 weeks. Safety results were similar to those seen with dupilumab for children aged 6 years and older.

Conjunctivitis and herpes infections were among the most common adverse events associated with dupilumab in the study, according to the statement.

The target action date for the FDA decision on this application is June 9, 2022.

The Food and Drug Administration has accepted a supplemental Biologics License Application (sBLA) for Priority Review of dupilumab to treat moderate to severe atopic dermatitis (AD) in children aged 6 months to 5 years, according to a statement from the manufacturers, Regeneron and Sanofi.

If approved, dupilumab would be the first biologic approved for children in this age group in the United States, according to the statement. The proposed indication is as add-on therapy for children with moderate to severe AD not adequately controlled with topical prescription therapies or for whom topical therapies are not advised. The FDA granted breakthrough therapy designation for dupilumab for the treatment of severe AD in children aged 6 months to 11 years in 2016.

Approximately 85%-95% of atopic dermatitis patients develop symptoms before 5 years of age, and these symptoms often continue into adulthood, with an increased risk of skin infections and a significant impact on quality of life, according to the statement.

The sBLA is based on data from a phase 3 pivotal study of 162 children aged 6 months to 5 years in which dupilumab was added to standard-of-care topical corticosteroids, presented in December 2021. In the study, dupilumab plus standard of care significantly improved skin clearance and reduced overall disease severity and itch at 16 weeks compared with standard of care alone. Overall, 28% of the children randomized to dupilumab achieved the primary endpoint of clear or almost-clear skin, compared with 4% with those on standard of care alone (P < .0001), according to the manufacturers. Patients in the dupilumab group received either 200 mg (for children weighing ≥ 5 to < 15 kg) or 300 mg (for children weighing ≥ 15 to < 30 kg) every 4 weeks. Safety results were similar to those seen with dupilumab for children aged 6 years and older.

Conjunctivitis and herpes infections were among the most common adverse events associated with dupilumab in the study, according to the statement.

The target action date for the FDA decision on this application is June 9, 2022.

When children with atopic dermatitis (AD) present to the clinic and their parents complain that no previously recommended medical therapies have worked, what’s the next step?

“Many patients who have failed topical steroids have never had adequate treatment,” Anna Yasmine Kirkorian, MD, chief of dermatology at National Children’s Hospital in Washington, said during the ODAC Dermatology, Aesthetic & Surgical Conference. “There is no lower age limit on the use of topical corticosteroids, and low potency corticosteroids are inadequate to treat severe eczema. The idea that only over-the-counter 2.5% hydrocortisone cream is necessary is not true,” she added.

“You also want to scrutinize the vehicle,” she said, noting that children are often prescribed cream formulations that hurt when applied, so parents stop applying them. “Ointments are generally the vehicles of choice in childhood,” she added.

It is generally not advised to use topical and oral antibiotics in children with AD, unless there are clear signs of infection. “If they’re just slightly oozy, don’t use them,” she continued. “Of course, every child or adult with eczema has Staph aureus on them, but most of the time, what you need to do is repair the barrier. We know that from data and common sense. When we repair their barrier, their rates of infection decrease.”

A focal area with pustules and pus should be cultured and treated, Dr. Kirkorian said. “Monotherapy with antibiotics is going to do nothing for you.” In cases of children with failure to thrive, she recommends referral to pediatric dermatology, allergy/immunology, GI, or genetics, as appropriate.

For children with severe AD, Dr. Kirkorian favors a rescue plan with a one-pound jar of triamcinolone ointment 0.1%. She recommends application of the ointment to all areas, including the face and scalp once nightly for 2 weeks, with a follow-up appointment at the end of that time. “If you just give people medicine and ask them to come back in 6 months, they are not able to comply with that and they don’t have faith that it’s going to work,” explained Dr. Kirkorian, associate professor of dermatology and pediatrics at George Washington University, Washington. At the end of 2 weeks, “the majority will have improved dramatically, and then you can implement maintenance therapy with topical calcineurin inhibitors, crisaborole, or possibly topical ruxolitinib.”

Some clinicians prescribe oral antihistamines for AD, but Dr. Kirkorian said that data supporting their use are limited and antihistamines are not approved for use in children younger than 6 months of age. Sedating antihistamines will induce sleep, “but do not provide durable night-long sleep,” and routine use may have an impact on learning and school performance. In addition, exposure to antihistamines in children under age 2 may be associated with development of ADHD at school age.

The interleukin-4 receptor alpha antagonist dupilumab (Dupixent) is approved by the Food and Drug Administration for moderate to severe AD in patients ages 6 and older. But obtaining it for patients can be tricky, she said, as this requires documented failure of corticosteroids, calcineurin inhibitors, crisaborole ointment, and phototherapy (if prescribed). Patients are often obligated to do step therapy with an off-label drug such as cyclosporine or methotrexate for 3 months, and they need to demonstrate responses with objective measures of severity such as the SCORAD (SCORing Atopic Dermatitis) and the validated Investigator Global Assessment.

“Most of my patients carry insurance that does not approve dupilumab without failure of a prior off-label systemic immunosuppressant medication,” Dr. Kirkorian said. Cyclosporine is her first choice for a systemic immunosuppressant “because it has a fast onset of action, it’s effective for treatment of atopic dermatitis, and safe for short-term use,” she said. “I don’t think that methotrexate works well for eczema. It can take weeks and weeks to work.”

She typically starts patients on a 5 mg/kg dose of cyclosporine. Baseline tests include CBC, CMP (comprehensive metabolic panel), lipids, and vitals. She repeats the labs at 1 month, and includes a blood pressure check. Potential adverse effects of cyclosporine include infections (including opportunistic infections), cytopenias, hypertension, nephrotoxicity, hepatotoxicity, neurotoxicity (including posterior reversible encephalopathy syndrome), electrolyte disturbance, lymphoma, and cutaneous malignancy.

“The good news is that we generally don’t see the adverse effects with short-term use,” Dr. Kirkorian said. “We will see some hypertrichosis and gingival hypertrophy, which resolves with cessation of therapy. There are serious side effects if you use it for long enough.”

As for methotrexate, “it is still a very important drug in pediatric dermatology, particularly in other conditions such as psoriasis,” she said. “The problem is that weekly dosing of methotrexate poses a greater risk of dosing errors. People aren’t really triggered to think of a once-weekly medication. If you do use it, give them a short supply to make sure that they come back, and that they don’t give it daily accidentally.”

Practical tips she offered for prescribing cyclosporine include supplying a patient handout with information on all adverse effects, dosing information, vaccination information, and pregnancy precautions, with contact information (a patient portal or on-call number) for the treating clinician in case a patient develops adverse effects. Administration of live vaccines while patients are on cyclosporine is not recommended.

When transitioning patients from cyclosporine or methotrexate to dupilumab, Dr. Kirkorian recommends tapering the immunosuppressant dose by half every 2 weeks to complete cessation by week 8 of treatment. For patients who experience a severe baseline flare once the immunosuppressant is tapered, despite the switch to dupilumab, she recommends restarting methotrexate at a full dose and then reducing the dose every 2 weeks until the lowest effective dose (2.5-5 mg weekly) is reached.

“Waning efficacy is real,” she said. “We can add methotrexate to recapture efficacy. Check for superimposed allergic contact dermatitis.”

With upadacitinib (Rinvoq), an oral Janus kinase (JAK) inhibitor recently approved for treating refractory, moderate to severe AD in patients 12 years of age and older, is the risk profile acceptable to parents and physicians? “I think the answer is yes,” Dr. Kirkorian said. “But we’re going to have to think through that very carefully. It’s going to be exciting to see how this drug changes management in our patients.”

Dr. Kirkorian disclosed that she is a member of the advisory board for Verrica Pharmaceuticals.

When children with atopic dermatitis (AD) present to the clinic and their parents complain that no previously recommended medical therapies have worked, what’s the next step?

“Many patients who have failed topical steroids have never had adequate treatment,” Anna Yasmine Kirkorian, MD, chief of dermatology at National Children’s Hospital in Washington, said during the ODAC Dermatology, Aesthetic & Surgical Conference. “There is no lower age limit on the use of topical corticosteroids, and low potency corticosteroids are inadequate to treat severe eczema. The idea that only over-the-counter 2.5% hydrocortisone cream is necessary is not true,” she added.

“You also want to scrutinize the vehicle,” she said, noting that children are often prescribed cream formulations that hurt when applied, so parents stop applying them. “Ointments are generally the vehicles of choice in childhood,” she added.

It is generally not advised to use topical and oral antibiotics in children with AD, unless there are clear signs of infection. “If they’re just slightly oozy, don’t use them,” she continued. “Of course, every child or adult with eczema has Staph aureus on them, but most of the time, what you need to do is repair the barrier. We know that from data and common sense. When we repair their barrier, their rates of infection decrease.”

A focal area with pustules and pus should be cultured and treated, Dr. Kirkorian said. “Monotherapy with antibiotics is going to do nothing for you.” In cases of children with failure to thrive, she recommends referral to pediatric dermatology, allergy/immunology, GI, or genetics, as appropriate.

For children with severe AD, Dr. Kirkorian favors a rescue plan with a one-pound jar of triamcinolone ointment 0.1%. She recommends application of the ointment to all areas, including the face and scalp once nightly for 2 weeks, with a follow-up appointment at the end of that time. “If you just give people medicine and ask them to come back in 6 months, they are not able to comply with that and they don’t have faith that it’s going to work,” explained Dr. Kirkorian, associate professor of dermatology and pediatrics at George Washington University, Washington. At the end of 2 weeks, “the majority will have improved dramatically, and then you can implement maintenance therapy with topical calcineurin inhibitors, crisaborole, or possibly topical ruxolitinib.”

Some clinicians prescribe oral antihistamines for AD, but Dr. Kirkorian said that data supporting their use are limited and antihistamines are not approved for use in children younger than 6 months of age. Sedating antihistamines will induce sleep, “but do not provide durable night-long sleep,” and routine use may have an impact on learning and school performance. In addition, exposure to antihistamines in children under age 2 may be associated with development of ADHD at school age.

The interleukin-4 receptor alpha antagonist dupilumab (Dupixent) is approved by the Food and Drug Administration for moderate to severe AD in patients ages 6 and older. But obtaining it for patients can be tricky, she said, as this requires documented failure of corticosteroids, calcineurin inhibitors, crisaborole ointment, and phototherapy (if prescribed). Patients are often obligated to do step therapy with an off-label drug such as cyclosporine or methotrexate for 3 months, and they need to demonstrate responses with objective measures of severity such as the SCORAD (SCORing Atopic Dermatitis) and the validated Investigator Global Assessment.

“Most of my patients carry insurance that does not approve dupilumab without failure of a prior off-label systemic immunosuppressant medication,” Dr. Kirkorian said. Cyclosporine is her first choice for a systemic immunosuppressant “because it has a fast onset of action, it’s effective for treatment of atopic dermatitis, and safe for short-term use,” she said. “I don’t think that methotrexate works well for eczema. It can take weeks and weeks to work.”

She typically starts patients on a 5 mg/kg dose of cyclosporine. Baseline tests include CBC, CMP (comprehensive metabolic panel), lipids, and vitals. She repeats the labs at 1 month, and includes a blood pressure check. Potential adverse effects of cyclosporine include infections (including opportunistic infections), cytopenias, hypertension, nephrotoxicity, hepatotoxicity, neurotoxicity (including posterior reversible encephalopathy syndrome), electrolyte disturbance, lymphoma, and cutaneous malignancy.

“The good news is that we generally don’t see the adverse effects with short-term use,” Dr. Kirkorian said. “We will see some hypertrichosis and gingival hypertrophy, which resolves with cessation of therapy. There are serious side effects if you use it for long enough.”

As for methotrexate, “it is still a very important drug in pediatric dermatology, particularly in other conditions such as psoriasis,” she said. “The problem is that weekly dosing of methotrexate poses a greater risk of dosing errors. People aren’t really triggered to think of a once-weekly medication. If you do use it, give them a short supply to make sure that they come back, and that they don’t give it daily accidentally.”

Practical tips she offered for prescribing cyclosporine include supplying a patient handout with information on all adverse effects, dosing information, vaccination information, and pregnancy precautions, with contact information (a patient portal or on-call number) for the treating clinician in case a patient develops adverse effects. Administration of live vaccines while patients are on cyclosporine is not recommended.

When transitioning patients from cyclosporine or methotrexate to dupilumab, Dr. Kirkorian recommends tapering the immunosuppressant dose by half every 2 weeks to complete cessation by week 8 of treatment. For patients who experience a severe baseline flare once the immunosuppressant is tapered, despite the switch to dupilumab, she recommends restarting methotrexate at a full dose and then reducing the dose every 2 weeks until the lowest effective dose (2.5-5 mg weekly) is reached.

“Waning efficacy is real,” she said. “We can add methotrexate to recapture efficacy. Check for superimposed allergic contact dermatitis.”

With upadacitinib (Rinvoq), an oral Janus kinase (JAK) inhibitor recently approved for treating refractory, moderate to severe AD in patients 12 years of age and older, is the risk profile acceptable to parents and physicians? “I think the answer is yes,” Dr. Kirkorian said. “But we’re going to have to think through that very carefully. It’s going to be exciting to see how this drug changes management in our patients.”

Dr. Kirkorian disclosed that she is a member of the advisory board for Verrica Pharmaceuticals.

When children with atopic dermatitis (AD) present to the clinic and their parents complain that no previously recommended medical therapies have worked, what’s the next step?

“Many patients who have failed topical steroids have never had adequate treatment,” Anna Yasmine Kirkorian, MD, chief of dermatology at National Children’s Hospital in Washington, said during the ODAC Dermatology, Aesthetic & Surgical Conference. “There is no lower age limit on the use of topical corticosteroids, and low potency corticosteroids are inadequate to treat severe eczema. The idea that only over-the-counter 2.5% hydrocortisone cream is necessary is not true,” she added.

“You also want to scrutinize the vehicle,” she said, noting that children are often prescribed cream formulations that hurt when applied, so parents stop applying them. “Ointments are generally the vehicles of choice in childhood,” she added.

It is generally not advised to use topical and oral antibiotics in children with AD, unless there are clear signs of infection. “If they’re just slightly oozy, don’t use them,” she continued. “Of course, every child or adult with eczema has Staph aureus on them, but most of the time, what you need to do is repair the barrier. We know that from data and common sense. When we repair their barrier, their rates of infection decrease.”

A focal area with pustules and pus should be cultured and treated, Dr. Kirkorian said. “Monotherapy with antibiotics is going to do nothing for you.” In cases of children with failure to thrive, she recommends referral to pediatric dermatology, allergy/immunology, GI, or genetics, as appropriate.

For children with severe AD, Dr. Kirkorian favors a rescue plan with a one-pound jar of triamcinolone ointment 0.1%. She recommends application of the ointment to all areas, including the face and scalp once nightly for 2 weeks, with a follow-up appointment at the end of that time. “If you just give people medicine and ask them to come back in 6 months, they are not able to comply with that and they don’t have faith that it’s going to work,” explained Dr. Kirkorian, associate professor of dermatology and pediatrics at George Washington University, Washington. At the end of 2 weeks, “the majority will have improved dramatically, and then you can implement maintenance therapy with topical calcineurin inhibitors, crisaborole, or possibly topical ruxolitinib.”

Some clinicians prescribe oral antihistamines for AD, but Dr. Kirkorian said that data supporting their use are limited and antihistamines are not approved for use in children younger than 6 months of age. Sedating antihistamines will induce sleep, “but do not provide durable night-long sleep,” and routine use may have an impact on learning and school performance. In addition, exposure to antihistamines in children under age 2 may be associated with development of ADHD at school age.

The interleukin-4 receptor alpha antagonist dupilumab (Dupixent) is approved by the Food and Drug Administration for moderate to severe AD in patients ages 6 and older. But obtaining it for patients can be tricky, she said, as this requires documented failure of corticosteroids, calcineurin inhibitors, crisaborole ointment, and phototherapy (if prescribed). Patients are often obligated to do step therapy with an off-label drug such as cyclosporine or methotrexate for 3 months, and they need to demonstrate responses with objective measures of severity such as the SCORAD (SCORing Atopic Dermatitis) and the validated Investigator Global Assessment.

“Most of my patients carry insurance that does not approve dupilumab without failure of a prior off-label systemic immunosuppressant medication,” Dr. Kirkorian said. Cyclosporine is her first choice for a systemic immunosuppressant “because it has a fast onset of action, it’s effective for treatment of atopic dermatitis, and safe for short-term use,” she said. “I don’t think that methotrexate works well for eczema. It can take weeks and weeks to work.”

She typically starts patients on a 5 mg/kg dose of cyclosporine. Baseline tests include CBC, CMP (comprehensive metabolic panel), lipids, and vitals. She repeats the labs at 1 month, and includes a blood pressure check. Potential adverse effects of cyclosporine include infections (including opportunistic infections), cytopenias, hypertension, nephrotoxicity, hepatotoxicity, neurotoxicity (including posterior reversible encephalopathy syndrome), electrolyte disturbance, lymphoma, and cutaneous malignancy.

“The good news is that we generally don’t see the adverse effects with short-term use,” Dr. Kirkorian said. “We will see some hypertrichosis and gingival hypertrophy, which resolves with cessation of therapy. There are serious side effects if you use it for long enough.”

As for methotrexate, “it is still a very important drug in pediatric dermatology, particularly in other conditions such as psoriasis,” she said. “The problem is that weekly dosing of methotrexate poses a greater risk of dosing errors. People aren’t really triggered to think of a once-weekly medication. If you do use it, give them a short supply to make sure that they come back, and that they don’t give it daily accidentally.”

Practical tips she offered for prescribing cyclosporine include supplying a patient handout with information on all adverse effects, dosing information, vaccination information, and pregnancy precautions, with contact information (a patient portal or on-call number) for the treating clinician in case a patient develops adverse effects. Administration of live vaccines while patients are on cyclosporine is not recommended.

When transitioning patients from cyclosporine or methotrexate to dupilumab, Dr. Kirkorian recommends tapering the immunosuppressant dose by half every 2 weeks to complete cessation by week 8 of treatment. For patients who experience a severe baseline flare once the immunosuppressant is tapered, despite the switch to dupilumab, she recommends restarting methotrexate at a full dose and then reducing the dose every 2 weeks until the lowest effective dose (2.5-5 mg weekly) is reached.

“Waning efficacy is real,” she said. “We can add methotrexate to recapture efficacy. Check for superimposed allergic contact dermatitis.”

With upadacitinib (Rinvoq), an oral Janus kinase (JAK) inhibitor recently approved for treating refractory, moderate to severe AD in patients 12 years of age and older, is the risk profile acceptable to parents and physicians? “I think the answer is yes,” Dr. Kirkorian said. “But we’re going to have to think through that very carefully. It’s going to be exciting to see how this drug changes management in our patients.”

Dr. Kirkorian disclosed that she is a member of the advisory board for Verrica Pharmaceuticals.