Dr Peter Lio Discusses Factors Impacting Pediatric Atopic Dermatitis Disease Course

In an interview, Peter Lio, MD, a dermatologist and clinical assistant professor at Northwestern Feinberg School of Medicine, chronicled a number of factors that can impact the disease course of atopic dermatitis in children, including lifestyle and environmental factors.

Lio presented on the topic at the Society for Pediatric Dermatology 2024 annual conference, which was held from July 11 to July 14 in Toronto, Canada.

This transcript has been lightly edited for clarity.

Transcript

How effective are current treatment options in modifying the long-term course of pediatric atopic dermatitis?

This is such a critical question at this time because I think we're seeing a few different competing ideas play out. And the short answer is we don't know. The longer answer is, we think there might be something to this, though.

And the 2 signals are first, that there really is the potential for disease modification, as a concept. And I believe strongly in this because I talk about atopic dermatitis as being a disease of vicious cycles, that the barrier starts to fall apart, the microbiome follows, the immune system responds, then there's a behavioral piece where people are scratching. If you disrupt that it really does seem to follow that you can then go from that vicious cycle downward to a virtuous cycle where everything's getting more back in harmony in a better state that can actually, I think, be resilient. So there's that piece, can we change the course? And I think the answer is probably yes.

The second piece is, can we also change some of the allergic comorbidities that come along with it? And I think, again, tentative maybe. And the reason is, is because we think a lot of allergies happen through this process called epicutaneous, or transcutaneous sensitization. The broken skin barrier allows allergens and irritants to get into the skin.

So if we could heal the skin and protect it from an early point, is it not possible that we could then prevent the progression and development of other diseases? And the answer is maybe. Some of the early studies suggest that there's a signal. There was a neat study showing that aggressive care of atopic dermatitis early on did seem to decrease the development of food allergy in a cohort, but it was kind of a contrived study, so we need to see it play out.

What evidence supports the use of systemic therapies, such as biologics, in changing atopic dermatitis disease progression in children?

I think we understand that undertreated atopic dermatitis is way too common, and we hear it over and over and over. We see patients who are just not where they need to be.

Topicals are amazing for a lot of patients, and I would argue they're also important for everybody, no matter how severe you are. If there's going to be some role for topicals, you're going to be using topicals. But I think a lot of patients really do need to be on a systemic agent, because we know, for example, that even skin that looks normal, is often not really normal. It's sort of normal-ish, but it's not quite baseline. And so we really think there's a role for more systemic therapy. And that really brings up that point of if we treat people appropriately, and I would argue whether or not you need systemic therapy, but if we treat appropriately and many patients, I think do need systemics, I think we potentially can modify the disease or at the very least, enter into a state of relative remission.

This is something I see played out every single day in clinic, where we have people who are out of control, we get them better again—plus or minus systemics. I don't think you always need a systemic. For milder or more limited disease, you might be able to do the same thing with topicals. But for many patients, probably more than we think systemics are helpful. What we find is that we can then decrease their medication, we can increase the interval between it, or sometimes even stop it completely. And that's kind of mind boggling, to see a patient who is totally out of control now saying, "I'm pretty good. I don't really need a whole lot."