Dr Robert Sidbury: Best Practices for Managing Atopic Dermatitis in Infants

At the eighth annual Revolutionizing Atopic Dermatitis (RAD) conference, Robert Sidbury, MD, MPH, professor of pediatrics at Seattle Children's Hospital, presented on the topic of infant atopic dermatitis (AD), which often presents itself differently than in children and adults.

Sidbury also discusses some of the barriers to care in infant AD, and how physicians can approach these challenges to improve patient outcomes.

The American Journal of Managed Care^® (AJMC^®): What are some of the barriers to care in infant AD, and how can practices and physicians approach these barriers to help their patients?

Sidbury: I think that some of the barriers to care are a natural tendency and reluctance to treat infants; a fear that they might have a greater risk of side effects and in certain settings, in “preemies” with a truly less capable or competent skin barrier. That's true to a certain extent. We have to be cognizant, and we use lower potency products. There are all sorts of concessions we make to that.

But there's a pendulum swinging to the extent of, “Oh, boy, let's not use anything pharmaceutical. Let's not do anything because it might cause harm.” And that is something that I always want to impress upon the parents and the providers if they are of that ilk that are reluctant to treat, what the cost of not treating is: that these babies are miserable, they're itching, they sometimes are not gaining weight properly because their eczema is so severe. That's probably one of the big barriers.

Another big barrier is the role of food allergy. It's a big topic, it could be a conference alone on its own weight. But some simple things are that kids with atopic dermatitis are more susceptible and do have a greater risk of food allergies.

The challenge is that most times, it's not one single thing—even if they are allergic—that you can remove and then all of a sudden everything's better. What I always advise parents and providers to do is take a good history, and if the history is sort of ambiguous, not compelling, then don't adjust or mess with the food or with the diet. Mess with the treatment. Mitigate that irritancy, and treat the inflammation. And if they get better without changing the diet, then the questions of food allergy tend to melt away.

AJMC: Does the presentation of AD in infants differ from other age groups?

Sidbury: I called out infants 2 months of age and younger—so preemies, you do the math, you make sure where they are, and how competent their skin barrier is.

But with the younger infants, we're certainly more aware. We use weaker products. We try to just use nonpharmaceutical things if we can, but sometimes you can't. And then you use weaker products and step up as you need to go. For sure, we think about infants in different ways. But, by and large, the core features, the foundational elements of treating atopic dermatitis—minimizing irritants, good skincare, proper bathing, and moisturization—all nonpharmaceutical and those are the same.

AJMC: Are there any preventive measures or strategies to reduce the likelihood of AD flare-ups and minimize the need for acute interventions?

Sidbury: Yeah, A lot of those things we talked about with barriers and good skincare. Harkening back to what I just mentioned a moment ago about bathing moisturization. That's an area of huge, not controversy, just confusion, primarily with parents.

Oftentimes with primary care providers—sometimes the dermatologist to be honest—the fundamental question “is bathing good or bad for atopic dermatitis?” And the answer to that is "yes." That's because it can be either and that's why it's confusing.

It's really important to take the time, because the parents have already "learned" a lot from the internet. And they've learned sometimes the right thing—sometimes the wrong thing—from their primary care provider. Then they come to us, and we will sometimes give them mixed messages as well.

This idea is not this monolith within dermatology, even. It's a place that we really need to take the time to spend with the parents to make them understand the role of bathing and moisturization.

How do we do that? I can't just say words. Why would they believe me over their pediatrician? They should not. I have to buy their trust by getting them to see what's happening. I'll show them their child. And [in the presentation, Elaine C. Siegfried, MD,] showed a wonderful slide of a baby where they were pretty much head to toe with bad eczema, but the diaper area was pristine. And that just pointed out how areas that are protected and moist tend to do better.

The underarms? Excellent, same! And so, sometimes you can see that in a child, and you can use that to show the parents. Whatever you read on the internet, whatever you heard from your pediatrician, whatever you heard maybe from another dermatologist, let's forget it. Let's just look at your child and see what their skin likes. It likes constant moisture. It doesn't like wet, dry, wet, dry. Somehow, we need to create those factors in places that may be hard to create those factors—around the mouth where it's wet, dry, wet, dry with foods, we need to try to mitigate that. That's probably the probably the biggest things that I try to go through with parents to try and disabuse false notions that they've learned.

This transcript has been lightly edited for clarity.