Dr Larry Eichenfield: A Changing Therapy Landscape Provides More Options for Infants With AD

At the eighth annual Revolutionizing Atopic Dermatitis (RAD) conference, Larry Eichenfield, MD, professor of dermatology and pediatrics and vice chair of the Department of Dermatology at the University of California San Diego (UCSD) School of Medicine, and chief of pediatric and adolescent dermatology at Rady Children's Hospital San Diego, shares key points he hopes physicians will take away from his session on choosing the right treatments and therapies for atopic dermatitis (AD) in infants.

AJMC®: What are key takeaways from your session you presented on for clinicians who treat patients with AD?

Eichenfield: There are these incredible changes happening in the field of atopic dermatitis and really a revolution of systemic therapy. And, as we've learned more about atopic dermatitis, and as we have the introduction of new therapies, it's fairly new that we're really sort of morphing our perspective on treating infants with systemic therapy.

We certainly never had approved systemic agents in younger children for atopic dermatitis, and the introduction of dupilumab as the first one when they did a study that was basically under 6 years of age but included children 6 months to 2 years of age in that clinical study, and the approval is down to 6 months of age. It's really sort of changed our perspective. And so, one of the takeaways is clearly that this is a rapidly changing perspective, and that we're recognizing that when we have very, very severe disease that isn't adequately coming under control, we're much more liberal at using systemic therapies as compared to when we didn't have biologic agents and we had the options of either corticosteroids or cyclosporine, Imuran, or other chemotherapeutic or immunosuppressive agents that were much more significantly negatively impacting the health of the individual.

AJMC®: Are there any oral medications or systemic treatments that may be recommended for severe cases of AD among infants?

Eichenfield: Right now, we actually have dupilumab, a specific IL-13 [interleukin 13] blocker that's been approved for atopic dermatitis down to 6 months of age. As I pointed out in my discussion today, there's actually only 6 children in the study who were dosed with dupilumab at 6 months to 2 years of age, but there's a lot more around the world who've been treated since approval, and that's really the first specifically indicated systemic therapy.

Previously, people would have used occasionally cyclosporine methotrexate or other immunosuppressives. But the literature on that sort of reflects that there was very hardly any literature and hardly any use. [Dupilumab] has probably become the predominant systemic agent for severe atopic dermatitis. Especially those infants who present with severe atopic dermatitis that's compromising their function, their growth, we have a lot of failure to thrive in some of those individuals. And if we're comfortable that it is truly atopic dermatitis and is not part of an immunosuppressive syndrome or genodermatosis, it can be incredibly helpful in the management of disease.

AJMC®: Can you provide information about any alternatives or complementary therapies to systemic therapy that might be beneficial in treating AD in infants?

Eichenfield: Of course, we still start with our topical steroids and topical non-steroid agents, trying to see if we can get infants adequately under control and keep them under control with a variety of standard complementary, and alternative—which isn't really complementary and alternative, right. We start off with really good skincare, trying to get the skin barrier improved with moisturizers, avoiding specific allergens or irritants in patients. That's part of a general care regimen. Then we use anti-inflammatories as needed with topicals, and now we have systemic agents as well.

There's a lot of other what would be called complementary and alternative agents that have been used in atopic dermatitis, but we have a limited evidence basis. So, prebiotics and probiotics, people looking at whether we can impact on dietary manipulation for changing atopic dermatitis. Part of our session here at the RAD meeting was discussing the place of allergy with a pretty negative perspective on dietary avoidance as an adequate measure for treatment of atopic dermatitis in young infants.

And I’ll broadly say there's a lot of other stuff that people use, whether it be in Germany they use a lot of black tea soaks as a topical soak; I think that'd be called complementary and alternative therapy. And there's other therapies that just aren't adequately tested to know how useful they are across the population.

AJMC®: What are common triggers for pediatric AD and what are the signs of a flare up?

Eichenfield: The signs of the flare up are pretty straightforward. With severe eczema flares, you have what I call the morbidities of the disease. You have eczema, the oozing, weeping, erythema, diffuse papular rash, secondary crusting, and an associated xerosis with a symptom of itch. That's the core.

A secondary bacterial infection is incredibly common because colonization, both with staph and strep, and occasionally with herpes, secondary infections can be very commonly part of the presentation of severe atopic dermatitis. So that's a sort of core presentation.

The course of the disease, though, varies incredibly, where we have patients who may have severe flares, and then they calm down appropriately with normal topicals, and they may not have persistent flares. But we have other individuals who have very persistent disease, or others where it's a waxing and waning course. But acute symptoms and signs go along with that flare of a disease and generally will move us to do a different intervention to control it.

AJMC®: Is there a long-term management plan for AD in infants? And what can you recommend to parents of infants with AD to prevent future flare ups?

Eichenfield: I think the plan is that we need to get the disease under control, and we need to get to keep it under control. So, we want to set a high expectation.

Simply, my spiel is we want to go to minimal rash, minimal itch, and minimal sleep disturbance; and if we do that, we'll probably minimize the overall negative impact of the disease on the life of the individual, potentially both aspects of the disease and then comorbidities that can develop as well. And that's what I'm going for, and I lay that out there.

Now, that that might be with just general skincare in a milder patient; it may be with general skincare and intermittent topical steroids or non-steroids In a patient who's a little bit more than that very, very mild patient. It could be systemic therapy in a moderate-to-severe patient who otherwise isn't getting better. But the outcome we're going for is for long-term disease control. We don't want patients to just put up with a disease and then wait for them to outgrow it. That's not a model.

It's recognized that we should have the tools now with what we have in hand and what's coming into our hands even more so with newer topicals and systemic agents, to manage most people's disease with minimal manifestations of the disease. And that's what we're going for.

This transcript has been lightly edited for clarity.