Pediatric Atopic Dermatitis: Skin Barrier Care and Early Biologic Use

Mark Lebwohl, MD, discusses skin barrier counseling, diet referral, and early biologic treatment in pediatric atopic dermatitis. Mark Lebwohl, MD, dermatologist, Dean for Clinical Therapeutics at the Icahn School of Medicine at Mount Sinai, and Chairman Emeritus of the Department of Dermatology at Mount Sinai, recently discussed the management of pediatric atopic dermatitis and the skin barrier.

He covered the role of diet in infants, the skin barrier instructions given to every patient, and the rationale for early biologic treatment. Role of Diet in Infants Most dermatologists care for pediatric patients, Lebwohl said, and some work alongside pediatric allergists. At Mount Sinai, infants are often referred to a pediatric allergy group to determine whether diet is contributing.

Patients in whom diet plays a role are taught to avoid the foods exacerbating their condition. “The vast majority of cases, diet does not play a role, but there are in pediatrics in particular a small but real number of patients in whom diet does play a role,” Lebwohl said. Skin Barrier Protection Instructions Lebwohl gives every patient an instruction sheet focused on skin barrier protection.

It recommends soap substitutes in place of soap, along with brief showers or baths limited in heat and duration. Patients then apply the prescribed topical therapy or a moisturizer immediately afterward. Some moisturizers contain therapeutic agents such as ceramides, which Lebwohl believes help the skin barrier.

Counseling also covers laundry materials, humidifiers in winter, and air conditioning in summer. “Every patient who comes in for atopic dermatitis, pediatric or adult, is given a sheet with instructions,” Lebwohl said. Bleach Baths for Impetiginized Skin When skin is impetiginized, Lebwohl may prescribe bleach baths to reduce bacterial burden.

Many patients with atopic dermatitis are colonized by Staph aureus, he said, and bleach baths would be prescribed for those patients. Early Treatment and the Atopic March Lebwohl referenced a poster from Eric Simpson, which he had already seen, on dupilumab in small children or infants.

Treatment resulted in a reduction in the atopic march, with fewer patients going on to develop asthma. He described the reduction among patients aged 2 to 5 as very impressive. Lebwohl noted the finding needs further proof, but if it bears out, it will reinforce the need to treat early.

Other reasons include bone growth, stature, and quality of life. “Those poor kids are miserable. Their parents are miserable.

The children don’t sleep, and the parents don’t sleep,” Lebwohl said. “Our drugs fortunately work quickly, and we need to use them when patients start out with atopic dermatitis. Not wait for them to be severe,” Lebwohl said.

The data have not changed his practice much, Lebwohl said, though they may make it easier to convince parents a biologic is needed. Parents care about their child’s height, and telling them their child will grow taller on a biologic, as opposed to topical therapies or systemic corticosteroids, leads to ready acceptance.

“Those parents readily accept the need for their child to go on a biologic therapy,” Lebwohl said. Related to this article