Welcome to the Don't Be Rash Pediatric Dermatology
Podcast, the owner's manual for your kid's skin.
I'm your host, Dr. K, board-certified pediatric
dermatologist and father of two boys. I'm here
to chat with you to promote dermatological education
and improve skin health in our children everywhere.
Let's get started. Welcome to Don't Be Rash,
the pediatric dermatology show, coming to you
from historic Bethlehem, Pennsylvania. I'm your
host and board-certified pediatric dermatologist,
Dr. Andrew Krakowski. On today's show, we're
going to continue our deep dive into the world
of eczema and focus on what it means to have
severe atopic dermatitis. More specifically,
in the first half of the show, we will discuss
what constitutes a diagnosis of severe atopic
dermatitis and discuss some of the potential
reasons why a child might end up at that level
of severity in the first place. Then in the second
half of the show, we will discuss management
approaches, including a discussion around systemic
therapies. Joining us today as our guest co-host
is world-renowned pediatric dermatologist, Dr.
Robert Sidbury. Dr. Sidbury is chief of pediatric
dermatology at Seattle Children's Hospital in
Washington State. He's really been a guiding
voice in terms of the approach to management
for patients with severe atopic dermatitis and
has been a leader on numerous expert panels and
consensus guidelines on the subject. Welcome,
Dr. Sidbury. Thanks for joining me today. Thank
you very much for having me, Dr. Krakowski. It's
a pleasure. So what comes to your mind clinically
when someone asks you about a child suffering
from severe atopic dermatitis? How's that different
from, say, mild or moderate in your mind? Well,
really just the misery of it, to be honest. It
is just such an all-encompassing thing with
sort of incessant itch, chronic sort of scratched
open skin, risk of infection. and all compounded
by the sort of injustice of oftentimes those
who see it, because as you know, eczema is a
very visible disorder, referring to it as "just
eczema" - my least favorite two words to put together
in the dictionary - because it may well capture
very, very mild eczema that gets better with
a little petrolatum, but it very much does not
capture this extent of disease. And I always
will tell pediatric residents even who rotate
with us and have that sort of misimpression of
the impact that this disease can have. It's like
if you've had some contact dermatitis, a poison
ivy, or a bug bite, and you're itching from it,
it can drive you batty. And that's a one - or
two-day proposition. This is a 24/7, 365 deal.
It is essentially that. Andrew was just sort
of trying to paint that picture of what severe
eczema is and how all-encompassing it is and
the lifestyle changes kids have to make to accommodate
it. The clothes they can't wear, the play dates
they can't have, the medicines they have to take,
both topically and systemically. All of that
sort of gets to this extent. And of course, as
you know, there are studies require metrics,
investigator global assessment scores, amount
of body surface area, depending on what you look
at, either more than 10 % or 15 % of the body
surface area. So there are all these ways that
we capture what is severe eczema, but it's really
that big picture of just how impactful it is.
Certainly, when you talk about body surface area
and sort of the, you know, is it totally clear,
mild, moderate, or severe, that misses the entire
picture of the psychological aspect of the condition
as well. And I think you alluded to it, but tell
us a little bit about what severe patients might
be experiencing from a psychological or psychosocial
perspective. Oh, it's tremendous. I mean, one
of the more fundamental things is the amount
of sleep loss that there is. And, you know, any
of us who have a bad night's sleep don't need
to be told the psychological impacts the next
day because our co-workers are probably telling
us. It is just incredibly impactful. And for
kids - I'm a pediatric dermatologist, so I will
speak specifically of the pediatric population,
but this is true for adults with poor performance
or impaired performance at work - but for kids,
their concentration is affected, their ability
to focus at school. Oftentimes, there's a question
of whether or not one of the comorbidities associated
with atopic dermatitis is attention deficit hyperactivity
disorder. That can be challenging, right? Because
they're losing so much sleep, they're tired and
they're inattentive. And so that can be sort
of a challenging thing to untangle. And I think
what's Really interesting as you probe deeper
into this. It's not just the child or the adult
patient It's the child affected by eczema and
then the parents who are also not getting a good
night's sleep either because the child's in the
other room keeping them up knocking on the door,
asking for help, asking for something to relieve
that itch, or we know the adults will sometimes
bring the child patient into the bed with them.
Now you have three people potentially, or more
than that, kicking, disturbing their sleep. Now
their work performance is suffering. That can
affect their employment. That can affect a promotion
that was competitive until, geez, "The last couple
of weeks, you look like you haven't slept, John.
I think we're going to go with Mary on this one!".
I think it kind of snowballs from that perspective.
Marital relations have been affected by other
children's suffering from this condition. So
to me, it's always interesting, not just the
patient, other kids too, even unaffected kids
within a family. They can't do some of the things
that they want to do. And it gets lost. That's
not captured as far as I'm concerned when you're
trying to make the case for a particular medication
to the insurance company or the prior authorization
team. You can't really objectively quantify that
easily. And it's unfortunate. Makes our job harder.
100%. Atopic dermatitis eczema is a family disorder.
It is not just the individual who suffers from
it. Oftentimes, because it tends to run in families,
it can be literally more than one patient who
was affected by it. But even if there's only
one, for all the reasons you say, if you want
to look at the data, a kid with moderate to severe
eczema loses 2 .1 hours of sleep a night. The
family, the parent, 1 .8. So they're all losing
sleep, and that plays out throughout their life.
We refer to comorbidities with ADHD. Well, one
of our recent guidelines that we've published
with the American Academy of Dermatology with
regard to adult comorbidities, depression, anxiety,
these things are more common in patients with
moderate to severe disease. So I 100 % agree
with what you've said. From a physical perspective,
what are some of the specific clues or clinical
signs that you're dealing with someone with now
severe atopic dermatitis rather than mild or
moderate? Are there any? Yeah, for sure. So if
we were doing a clinical trial, the sort of metrics
in the EASI score, which is one of the eczema area
and severity index, one of the things that we
try to capture, the clinical signs are erythema,
redness, papulation, bumpiness, excorations,
scratch marks, and lichenification. That idea
that the skin just looks like a hyperlinear,
extra lines in the skin because it's literally
thickened almost like a callus in shoes that
you wear that are too tight. And so those are
the sort of signs that we look for. And then
again, as we alluded a little bit earlier, that
surface area, that quantity, that extent of involvement,
we try to capture as well to put it all into
a score. But all of these things sort of factor
in. And you made a great point earlier where
even some of the clinical metrics that we're
using don't capture the extent of it. The EASI
score, the most commonly used metric, does not
include subjectives. It doesn't include anything
to do with what the patient's actually feeling.
So another one more commonly used in Europe,
but oftentimes used in studies done here too,
called a SCORAD, at least includes sleep loss
and itch. So there is that. But all of these
things factor into this sort of assessment that
we make. How do you approach either... colonization
or superinfection by a bacteria or in some cases
a virus like eczema herpeticum it does that exist
in your sort of clinical assessment as a standalone
criteria or quality or do you use the presence
of active infection to kick up the severity level
or and or do you use the history of recurrent
infections to change your severity level even
though the kid might be mild in your in your
exam room today, does that change the fact that
you would consider repeated infections as making
it more severe or less? Yeah, I do. I mean, those
are really significant things that require significant
interventions, whether it's in the mildest end
of the Staphylococcal bacterial infection spectrum
using a topical antibiotic versus something like
eczema herpeticum, which is a term we use to
suggest that a child with eczema has a Herpes
infection, which, you know, just to paint a picture,
typically if we think about HSV-1, herpes simplex
virus 1, a cold sore, quote unquote. right? Very
common. You know, you get a recurrent spot on
the lip. No one likes it. It is unpleasant for
everyone, but oftentimes people just let it go
and be untreated and it heals itself and may
recur in that same spot, but not as impactful
as it potentially could be. In a patient with
eczema, for reasons we now know, there's sort
of an ability to fight off infections in their
skin. Systemically, most kids with eczema, their
immune systems are very healthy and robust, but
In their skin, they have typically fewer what
we call antimicrobial peptides, almost like nature's
mupirocin, something just sitting on the skin,
helping us fight off infection. There's less
of it. They're called beta-defensins or cathelicidins.
There's less of it in patients with atopic dermatitis.
So they're not as easily able to fight off bacterial
infections, viral infections, and just sort of
an interesting corollary. I always teach my residents,
you know, they see patients with eczema and Staph
superinfection. in the emergency department all
the time because it's so common. Almost never
do they see a patient with psoriasis, another
chronic T-cell-mediated immune rash of the
skin. Almost never do you see them in the emergency
room with a Staphylococcal superinfection. And
that's because their beta-defensins, their cathelicidins,
their nature's mupirocin or antibiotic is normal
or upregulated, where in eczema, it's less. And
so there's a very ready explanation for that.
But 100%, if I see a kid who's getting recurrent
infection, even if - maybe by other metrics, they're
more mild - we're going to think about maybe not
only in our own mind and trying to make that
patient better, which is really what we're trying
to do, but trying to document and justify if
we feel they need more aggressive medications,
which we'll talk about the medication things
a little bit later, I think. We're going to need
to document that and say, hey, look, this is
their easy score, but hey, they've had two Staph
infections. They've had an eczema herpeticum.
This is something we need to address, and we
may need more aggressive medicines to do it.
How do you use the medicines or I should say
maybe interventions, because that's a little
bit more general, that the patient has tried
in the past as a way to either change or upgrade
their severity? Does that make sense? Do you
get what I'm asking? Yeah, for sure. And it's
an important discussion because I guess by definition,
if we're talking about this particular type of
patient, something's not going well. Either their
eczema is not responding as we had hoped or they're
getting superinfections. Either of those things
are not good and we need to figure out why. And
so if, let's take an example of, to answer your
specific question, this is a patient who's used
2 .5 % hydrocortisone and they come in to see
you and they say, I'm not getting better. Or
you can see they're not getting better. They've
had infections. Well, the first thing you want
to make sure is, are they actually using it?
Because that's a huge issue. I mean, none of
us are perfect with medicine adherence. Not a
single person. Not present company included.
Not anyone probably listening to this podcast.
But it's even harder for a patient who has to
do something. daily, topical, not very pleasant
for many folks to adhere. So there's literally
the challenges of adhering. And then there's
the fear, potentially, of some of the medications
we prescribe. And if we don't address those fears
and bring them out and give proper space for
the parents to explain their fears and then address
them, maybe or maybe not reassure them. But if
you don't reassure them, you would know that
that's a problem so you can move on. on to a
different medication. But those are the sorts
of things I think, Andrew, to answer your question,
that I try to think about when I see a patient
in that context. Do you have any tips or tricks
for how you assess if the patient's actually
using the medicines that you give them? Well,
first of all, I will... Ask them. I mean, in
a study, in a clinical trial, we'll weigh tubes,
right? So we will actually weigh the tubes, have
them bring them back, weigh them, and see. In
a regular clinic visit, it really is my biggest...
tip or trick with regard, let's just talk specifically
about topical steroids now. We may be getting
ahead of ourselves, but my biggest tip there
is, number one, to not be dismissive of those
concerns. Hopefully, before I ever prescribe
them, I've gone through, number one, this is
a topical steroid that have been around for 75 years.
We've got a ton of experience with them. They
are not the steroids that you see banned from
professional sports leagues. This is a very,
very different thing. So I start there. And then
I'll go, okay, what are we worried about? And
depending on the age of the child, if it's a
two-month-old preemie, I may very much be worried
about the absorption and what's going inside
of the topical steroid. So we'll talk about that
and how we mitigate that risk. More often, it's
an older child with maybe focal atopic dermatitis
patches and plaques and itchy areas. And I'll
say, listen, this two-year, four- or five-year
-old child, you know, one of their hands, not
my hand, one of THEIR hands is 1% of THEIR body
surface area. Let's say they have it on both
elbows, both knees. That's what? Barely 2%, 3
% of their body surface area. They are not going
to absorb enough to matter inside. So let's not
worry about that. But then there like, what about
thinning of the skin? They've always heard, oh
God, topical steroids can thin the skin and they
can. But if that's where you leave it, they've
read that online. They've heard that from their
topical, from their topical steroid. They've
heard that from their pediatrician. If that's
where you leave it. You know, what is that? Is
that bad? Does it go away? So what I try to do
with that is I will take them through what it
is and say, first of all, for the reasons we're
talking about it, we're going to use the right
strength in the right areas for the right amount
of time. So what we're about to describe is never
going to happen. But just in case, here's what
it would look like. And oftentimes on a little
baby, because that's where fears are most acute
for parents, especially providers too. I'll point
to the temple because the temple is an area where
it rarely gets eczema. So they haven't used any
topical steroids there. And every baby, the skin
is just very tight. And so you can see a little
vein traversing that area, which is a little
more subtle than if you look through your wrist
or my wrist or other areas where you can always
see veins. And I'll say, so if you see something
like that here. Or here, pointing to my cheek
or my elbow, places where you hadn't seen that
vein before. Perhaps that's the first sign of
thinning of the skin. Well, guess what? It's
entirely reversible. So I kind of take them through
that so they know that there's not this condition
that they hope and expect and have been told
will get better with time. And then they create
a problem that won't. So I try to let them know,
kind of empower them to be able to see what that
thing they're so worried about is at a time when
we can all recover from it. I totally agree.
I do everything that you just said. And then
if I'm lucky, quote unquote, the patient has
some lichenification, some thickening of the
skin. This is exactly what we're trying to treat.
So in a way, one of the potential side effects
is going to actually be used. for good, and we're
going to thin that skin back to normal, we're
not going to go past normal, right? And then
I always talk about how it's different around
or on the eyelids, around the eyes, on the eyelids,
that can cause other problems separate from thinning
of the skin. Your child doesn't have any need
to put a topical steroid anywhere near their
eyes, you know, so don't, right? What I've found
probably two things that have really kind of
changed the way I talk with my patients in the
exam room one actually I have to give credit
where credit's due my former colleague, mentor
Larry Eichenfield, MD used to make them bring their
tubes in physically and it might be a 30-gram
tube it might be a 15-gram tube - geez you would
hope not - but usually it's a 30- or 60-gram tube
and he would say okay first off to your point
"How come this hasn't been opened yet, right?"
Well, I just got it refilled. That's a lot different
than you've had this for three months and you're
telling me nothing's working. This is the first
tube. You haven't refilled it once and the seal's
not even broken on it, right? So that reframes
the conversation. But more often than not, it's
open and something's been removed from it. But
you can say, okay, I expect you to use this medicine.
once or twice a day. Are you a, are you a two
times a day guy or one time a day guy? Generally
twice a day twice at it. Me too. So, twice a day
and in general depending of course what strength
I'm using like I don't really want you to use
it more than two weeks without at least letting
me know if something something's probably not
right if you have to keep using this medicine
more than two weeks and you're not getting any
effect and I'll couch that and say, you know
if it's if it's almost clear and you're hitting
day 14 go ahead and use it until until 15 or
16 and you're fine. But how much of this medicine
do you think, using this tube as your example,
how much of the medicine do you expect to go
through in those two weeks? And I've found that
I'm 100% shocked that they might say, oh, a
quarter of the tube, of a 30-gram tube. Well,
no, your child's 12 years old. 60 kilograms.
You're going to be going through two 30-gram
tubes pretty easily. And oh, wow, I'd never really
thought of it that way. So physically telling
them, I want you to go through this tube in one
week, of course, depending on the size of the
tube again, but that's the amount of medicine
I expect you to be using on a weekly basis, I've
found to be very powerful. And then I also, I've
learned from the way I've written prescriptions,
I've always tried to write using no abbreviations.
I hate abbreviations. And I think it's just confusing
to say A -A -A -B -I -D -X -2 -W -K -S. Apply
to affected area twice a day for two weeks. That
doesn't mean anything to anybody except the pharmacist.
So I'll write out pretty detailed instructions,
including I want you to take a week off between
using. And what I've learned is that's the message
was lost. If you're using it on your LEFT elbow
crease, for example, in my mind, it's still quite
reasonable to use it on your RIGHT elbow crease
if a new rash flare pops out or behind your knee
or wherever you might use it but I've learned
from my patients that they said, "Oh, well you told
me not to use the medicine for that week" and
then they'll just let any new flare go untreated
for seven days and I missed that opportunity.
That's on me. That's just poor instruction. Have
you ever had anything like that pop up with your
patients? Oh, for sure. And it's just remarkable
how many times they'll come into a new visit,
and they'll say, "Okay, this triamcinolone, for
instance, works really well, but I was told I
could only use it for 15 days out of the month."
And eczema is not a "15 days out of the month"
proposition. And so you have to figure out how
to... I will always say, I will never say, "Oh,
that silly pediatrician, They don't know what
they're talking about." I'll say I 100 % agree
with that. What they're trying to communicate
there is that you need to take breaks. But let's
just delve into that a little further. Exactly
what you said in terms of different locations
is one element of it. Knowing also that there
are going to be times where they need to use
it a little longer. Their child catches a cold,
runny nose, whatever, seemingly having nothing
to do with the skin. Well, it's immune stimulation,
right? Your immune system is going to rev up
to get that virus gone, and that stimulates the
eczema. And so they may have an eczema flare
in the wake of a cold that makes them have to
have this burst of... treatment for a little
bit longer to kind of calm things down so all
of those things I 100 % agree with especially
the idea of oftentimes how far a medicine will
be able to go and how much they should use. Sometimes
see them come in with these tiny, not even 15
grams, these tiny little sample sizes, and that's
all they were given. And boy, it worked well
on that one square centimeter of my skin, but
probably not going to make a huge difference.
And then the last thing I'll say is, as you well
know, frequently eczema, when it gets better,
heals with some dispigmentation, some discoloration,
sometimes a little lighter, sometimes a little
darker. And I think there are two really important
messages there involved with that is number one,
if you, and many parents do, will sort of carefully
parse the adverse effects of topical steroids,
one of which can say can cause discoloration
and hypopigmentation, and it can, but it's also
really important to remember and much more common
that the skin, the eczema is healing and it's
that inflammation itself that the eczema, that's
what eczema is, that is causing that. temporary
not permanent discoloration and so i always want
to make sure that they realize that that's not
a side effect of of the the topical steroid and
then further on the other side of things is is
getting at not using too much with regard to
this discoloration is unless you tell parents
it doesn't look normal right that examine heals
and it looks abnormal. It's discolored. And yet
it's not inflamed anymore. It's flat. It's smooth.
It's not itchy. It's not red. And so what I'll
tell parents is, is if it's not bumpy, it's not
red, it's not itchy, just moisturize it. That's
just your healed eczema. And if you keep treating
with a topical steroid to that, yeah, you may,
number one, you don't need it. And number two,
you are increasing the risk that you might actually
cause a side effect. 100 % agree. I try to use
proactively the hypopigmentation, usually is
what I'm saying, as a sign you did your job.
I mean, you knocked out the red, rough, itchy
spots. If you can feel it, it's still flaring,
but a flat, paler skin is where that inflammation
was. i don't know if you have a spiel but i basically
say the inflammation sort of "stuns" or "makes the
cells that make your tan lazy" and they don't,
they're not working like they should
it takes i don't know i tell usually about anywhere
up to a year even a little longer sometimes for
that to come back totally normal but the point
is it should come back normally and you did what
you needed to do to make sure that it's now that
timer has been started and you know you would
expect the color going to be back hopefully by
next summer and it's going to get well that's
another good point it's going to get worse you're
going to see this more in the summer months because
the contrast around those spots is different
and then the winter is going to be a little bit
more blended in because you don't get that tan.
so yeah I totally agree, and I'll leverage that
further to sort of squeeze in yet another dermatologist
message, which is if you go out in the summer,
for the exact reasons you said, the quote -unquote
normal skin tans normally, and the dispigmented,
sort of hypopigmented skin doesn't, and so the
contrast makes it look worse. So therefore, sunscreen
will actually help you minimize that apparent
worsening in the summer with sun exposure. For
that, for hypopigmentation related to post inflammation,
I'm almost always saying I prescribe, quote unquote,
you a combination moisturizer sunscreen. And
there's a couple out there. But you pick one
of these three or four products is going to work.
And that's exactly what you need. It's got sunscreen
built in and it's moisturizing your skin. Maybe
I give them a little break from using something
thick during the summer that I would normally
have them being used in the winter. But that
works great. In this day and age of TikTok, unfortunately,
becoming some people's main source for education,
are you seeing the concept of topical steroid
withdrawal percolate into your clinic yet? Is
that a thing or have you managed to dodge that
bullet? Well, I'll say first of all, Andrew,
I have to send a thank you note to you because
I am a complete social media Luddite. And no
Facebook, not even Doximity, none of that stuff.
And my 18-year-old daughter is eternally embarrassed
at my naivete around these things. And so when
I told her I was doing a podcast with her, I
got so much credit. A podcast with you. I got
so much credit with her. So thank you for that.
No problem. You are absolutely right. It is a
source of information that is accessible. to
families and patients. And it's interesting and
it's engaging. And there is some good content
in there. My daughter has shared some of that
to sort of tell me it's not all bad, but it's
also unregulated. And goodness knows, what could
potentially be out there that's potentially a
challenge. And you mentioned one area of... controversy.
The idea of topical steroid withdrawal, which
I have no doubt is on TikTok. I haven't seen
those things, but I'm very aware of the problem.
And yes, I have encountered it. I use the word
controversial because there are folks who don't
think it exists. I'm not one of those folks,
though I also am not sure I've ever seen it in
a kid. I'll say that. I 100 % agree. That's actually
really funny because that's been my experience.
I've seen it in adults. I distinctly remember
a woman who had been treated for her facial rosacea.
You wouldn't believe this, I think, but beta
methasone - ultra potent steroid - twice a day,
every day for two years. On the face. On her
face. She came in with... the largest blood vessels
that you could see and she had stopped her steroid
and now was on top of that background of blood
vessels she had what looked like a demodex infection
it didn't turn out that it was but just hundreds
of pustules all over her face and I thought well
geez that's probably what topical steroid withdrawal
looks like but I've never seen it in a child
and I don't know if that's because I don't think
it's because kids are something special that
they couldn't get it. I just think we're smarter
about how we use the products. Is that fair or
is that crazy? I think it is fair. And I think
the other thing that sort of factors into that
is non-dermatologists. And this could be a problem
at the hands of a dermatologist, a non-dermatologist.
But I think non-dermatologists are also much,
much leerier. of using a very potent steroid
in a child than they might be in an adult. And
so I think that is the issue, is using extremely
potent steroids, oftentimes on the face, the
exact scenario you described, where I very much
think it's a real thing because I attend conferences
and all sorts of things where I see these patients
presented, they just aren't my own. And it's
difficult because there are no diagnostic
criteria. There are efforts being made to change
that, but it's a challenging scenario. And I'm
sure that TikTok can, hopefully there are some
sites on TikTok that maybe have some sensible
ideas about it, but I'm sure it can also potentially
fan the flames of controversy. Is it fair to
say, though, if you used... hydrocortisone 2
.5 % ointment or triamcinolone 0 .1 % ointment
of medium strength. Even the one that I'll use
probably as my strongest quote -unquote go -to
would be fluocinonide ointment. I'm very rarely
using clobetasol. And if I do, it's on the hands
or feet or very thick area, very short limited
amount of time. But those are kind of the three
steroids that I'll use on a stepwise approach.
Any three... used twice a day for two weeks appropriately,
would you ever expect to see the condition of
"topical steroid withdrawal" associated with that
clinical scenario? Does that exist in your mind
as a possibility? Haven't we been taught never
to say "never" in medicine? Well, I'm going to
say "never." Okay. Yeah, I agree. That's a NEVER.
Unless, I don't even think if you could eat it,
I don't think you could even get, maybe the Lidex,
maybe the fluocinonide and you might be able to
do some sort of adrenal suppression, but I, geez,
I just don't think it could. I don't think it
could do it. No, I agree with you. Well, one
other aspect that I find always interesting from
an investigative perspective is when you have
a severe eczema patient and I'll put eczema in
quotes on this one and you've been treating them
like they have atopic dermatitis and everything
you're doing is. has been tried, done correctly,
not working, when do you take a step back and
say, geez, could this be a hypersensitivity reaction?
Could this be an allergic contact dermatitis?
Are there clues? Yeah, and just an important
thing to have in the back of your mind always.
because it's so easy for us to say, oh, must
be non -adherence to the medicine, must be, there
must be an allergen in the environment that we're
just missing, must be something, something. Well...
Step back. Exactly what you said. Step back and
make sure, okay, could this be something else?
We actually, just as part of our American Academy
of Dermatology Atopic Dermatitis Guidelines Committee
have just, it's not published yet, but it will
be in the next few months, put out a guideline
for adults with this exact scenario. What do
you do? What do you think of when things aren't
going as they should? diagnostically so that's
specifically what where where do you go what
do you think of and so um That absolutely is
something you should think of because there are
a number of things that can mimic atopic dermatitis.
In the pediatric population, it can range from
infestations like scabies to contact allergy,
less common in kids and adults, but absolutely
potentially a problem, to even some more severe
or more significant conditions. So that is what
I think of. You sort of go through, okay. Let's
step back. They're diagnostic criteria. We don't
use them much, but they exist, and they're wonderful
to be able to fall back on. Is there a family
history here? Does this itch? Is it in the proper
distribution? Does it wax and wane? Then you
can go through minor diagnostic criteria. Kind
of go through all of those things in your mind,
and then do appropriate tests if you need to.
Scrape the skin looking for a fungal infection
or for scabies. Biopsy if you need to. We don't
often, but it is potentially a viable way to
get. more information. So all of those things
need to be considered and potentially explored
when that scenario presents. You reminded me
when you were talking, I was a history major
in school before I ever thought about going into
medicine. And so I'm always fascinated when I
learn, or at least what I think I'm learning
about the historical perspective. Tell me if
I'm wrong, the story behind Protopic. And topical
calcineurin inhibitors, not necessarily just
Protopic. When they first came out, there was
no "black box" warning on them. The sort of the
gates were up in terms of how you could use these
medicines. And they weren't steroids. They did
not have the side effects or the purported side
effects as steroids might have. So people, as
I understood it, were using them willy-nilly
might be a way to say it. Hey, that's a red rash
that's raised. It looks like eczema. Put some
topical calcineurin inhibitor on that rash and.
I'll see you back in six months. And this is
the part where I'm asking rather than stating
historical fact. What I've been told is that
where that "black box" warning came was that some
patients were not responding, ultimately wound
up probably seeing a dermatologist, getting a
biopsy, only to find out, hey, what we just biopsied
was a skin cancer, a lymphoma. called mycosis
fungoides, or something that looks like that.
And then, of course, the big decision was, geez,
did the medicine cause your eczema to turn into
a lymphoma, or was the original diagnosis, always
lymphoma, just misdiagnosed as eczema? Do I have
the story pretty accurate? Yeah, you do. And
I guess, first of all, now I have to send you
a "thank you" note from my brother, who's a history
professor at Rice, so respect for that background.
But 100%. So these were the first non-steroidals
to come out that actually worked, right? I mean,
back in 2000, 2001, tacrolimus (Protopic), Pimecrolimus
(Elidel) - "Willy" and "Nilly," if you will - were the
ones that came out, and they worked. And they
were never studied in the United States in kids
under two years of age or never approved in kids
under two years of age. And yet, when our parents
and providers most worried about topical steroid
safety. kids under two years of age and so they
were used like water because they finally there's
a non -steroid that worked and here we go and
um that was seen by the fda that this off-label
use in infants was was was happening um as we
alluded a little bit earlier a very young two
-month -old preemie from head to toe eczema you
put enough on their skin head to toe twice a
day for a while it they are going to absorb enough
to matter. And so they were worried that there
were going to be potential risks that were not
studied that came from that off -label use. And
so five years later, the FDA looked at this and
affixed that "black box" warning. And some of that
had to do with the potential of biopsy having
shown mycosis fungoides. But as you say, mycosis
fungoides, that... publication that i alluded
to a moment ago that's coming out that's one
of the first things we say that can look like
eczema is mycosis fungoides and so was it that
was it eczema all along don't know um that that
was that was really the issue so i 100% agree
with that and to take that one step further the
way that i will reassure parents is you know
when those came out You know, tacrolimus, for
instance, a 0 .03 % for kids up to 15, 0 .1 %
for kids older than 15 and adults. Well, what
was studied before they were approved, a 0 .3%.
So an order of magnitude stronger than the weaker
one that's been approved for kids. And those
studies didn't even show significant absorption
in the trials that made anyone worry in two -year
-olds and older. But we've just got so much data
and position papers from American Academy of
Dermatology and allergists saying that that boxed
warning was an overreach, which on the one hand,
I appreciated because it did stop inappropriate,
off -label, sort of uncontrolled use of these
products. The flip side was you and I both have
patients for whom they're absolutely perfect,
perfect complements to the topical steroid use,
if not monotherapy, and yet parents are scared
by that box warning. Oh, and if you don't bring
that warning up before mom reads it on the
box from the pharmacist, you have lost that patient.
I think more often than not, they're done. "How
come Dr. Krakowski didn't tell me this could
cause lymphoma?" Right. Yeah. So that's a five
to 10 minute discussion. And that adds up if
you're doing it six to eight times a day. And
it's just "in the trenches" pediatric dermatology.
Exactly right. Rob, how do you use a referral
to an allergist for these severe patients? Specifically,
How do you partner with them? How do you maybe
maintain the same messaging? And how do you use
the objective test that they might ask for? Skin
prick or, geez, IgE, RAS, blood testing. Do you,
I guess, would be a good starting point. Yeah,
talk about a five to ten minute discussion for
the box warning with some urine inhibitors. There's
your one hour discussion with parents. I brought
my 600-page allergy report. Would you like to
read it? Oh my goodness. Yes. Well, I'll tell
you, I was super spoiled. One of my first stops
along the way was at Boston Children's where
literally right next door was Dr. Linda Schneider,
who is just, I'm sure you know, just a wonderful
pediatric allergist at Boston Children's. And
I was just like, wow, why do people find this
allergy dermatology? discussion is so challenging.
You just go next door and talk to this brilliant
woman and she distills it and then you see the
patient together and it's so easy. That didn't
turn out to be reality. So since I've sort of
been in the weeds with this because it's a tough
question. Andrew, as you know, because kids with
eczema are more likely to have food allergies.
We'll just stay there for now. Of course, there
are environmental allergies. There's contact
allergies. There's all sorts of things. But they're
more likely to have food allergies, for instance.
Especially the severe ones is what we're looking
at. Exactly. Especially the severe ones. And
the challenge is... That is true, but oftentimes
they're "co-passengers." One doesn't cause the
other. And there's not this food that's hidden
in the environment or the diet that the parents,
you know, what is eczema for a parent? It is
utter loss of control. It is watching their child
be miserable, lose sleep, get infections every
other day when they're doing everything they
can to prevent that. And it just keeps happening.
And what can they control? Their diet. And they've
got, oh, well, yeah, their food allergies are
more common. This is what I control. Let's restrict
the diet. Let's beat every allergy bush we can
to see if that's the problem. Sometimes it is,
but more often than not, it's not. And so that's
just a challenging thing to say, okay, let's...
And maybe this gets back to your sort of comment
about if you don't bring up the box warning,
you're going to be dismissed. And you should
be by that patient. If a parent comes in with
a child and they're like, I think this is food
allergies. And I've taken history. There's not
really a clear temporal link between any food
exposure and a flare. There may be not even a
very atopic family. Just this kid has eczema.
So I'm not really thinking very much that allergies
playing a big role there. But the parents are
really invested in it. thing I'm gonna say is
oh no that's silly let's forget about that I'm
gonna say for the reasons I just said I actually
don't think that's probably playing a big role
here but that's let's set that aside for now
let's not forget about it let's set that aside
and do A, B, C, D for your skin and come back without
changing your diet But doing all these good things
for the skin. And it's amazing how often kids
will come back. And if the parents see that and
know they haven't changed the diet, that's the
best allergy test there is. Because the prick
test, the RAS test, good tests, informative,
can sometimes provide a roadmap. There are also,
as you well know, a lot of false positives there.
And then you've got this child who is tolerating,
let's just say, dairy. So you take your history.
No, they don't seem to react when you take dairy.
But boy, I've heard dairy is a common allergy
in less tests. You get a test. It says, oh, RAS
test positive, Prick test positive for dairy.
Child still has bad eczema. Well, let's take
the dairy out. Well, if you take the dairy out
long enough, you can cause a dairy allergy. The
gut needs to see that protein to continue to
develop tolerance. And so testing is not always
just information. There can be a sharp edge to
that as well. Yeah, I totally agree with you
on that. For me, patch testing, I don't. I'm
sure you guys do that at Seattle Children's.
We have a pretty robust patch testing program.
And I do sometimes get surprised when I find
something that wouldn't normally be clinically
relevant. But geez, it's there. And you sometimes
do eliminate that and get some improvement. But
from an allergy perspective, we have basically
stopped recommending. the RAS testing. I just
don't find that it's that useful. If to your
point about the false positives, unless actually
I'll take a step back. If, if you're, if by RAS
testing, you're not allergic to your dog, then
I can say, geez, Fido has nothing to do with
this. Get that out of your head. You know, that
to me is useful, but otherwise I a hundred percent
agree with you that there is no greater test.
For is your child truly allergic to something
then? Or I should say, is your eczema being driven
by an allergy to something? Then let's treat
this eczema and prove to you without you doing
anything else that the eczema can get better.
And man, when that happens, something magical,
you can see it in the parents' faces. Again,
it's usually moms. Just take a, they breathe
a. sigh of deep, deep relief that they don't
have to change everything. And that guilt, right?
The guilt of, geez, could breastfeeding be causing
this? I can't even imagine what that would feel
like. And it's exhausting. And they get that
off their chest - literally and figuratively,
I guess - but yeah, interesting. So we're very
similar in that regards to how we approach that.
Shifting gears a little bit to talk about management.
We're going to get to systemic therapies. Any
tips or tricks that you have for your approach
to optimizing topical therapies? Do you do wet
wraps? Are you using bleach baths? Are you doing
anything else that we should be thinking about
before we move into discussion around using truly
a systemic therapy? Yeah, for sure. And I love
the way that you sort of led into topical therapy
by including baths and moisturizers, not just
leaping to medicines because it is the foundation
of care for eczema. And that includes even when
we talk about systemic therapies, continuing
to moisturize and hydrate skin is really important.
And it's another area we were just talking about,
the confusion surrounding allergy and its role
in atopic dermatitis. Well, parents come in completely
flummoxed about the role of bathing and moisturization
with regard to atopic dermatitis, specifically
bathing in particular. You know, they've read
or been told that by one person that bathing
is good, you should bathe every day for their
child with eczema. They may have seen an equally
reputable source who said, oh my gosh, your child
has eczema? You should bathe them as little as
possible, once a week or less. And so the first
thing I try to do is say that neither of your
sources, whoever told you A or B, even though
they're diametrically opposing viewpoints, are
necessarily wrong. Again, trying to not, you
know, a patient comes to me or to you, a specialist.
And we throw their pediatrician under the bus.
We're throwing ourselves under the bus. That's
just stupid because they have a trusted source
who they will continue their relationship with.
And so we have to embrace that and integrate
ourselves into that. And so what I'll say is
that is not wrong. What they told you is not
wrong. However, here is... Here's the key part.
And oftentimes you can point to a child, especially
a severe infant, because oftentimes they'll have
their cheeks are red right around their chest
where they drools. It's all red and itchy, patchy
everywhere. And sometimes now babies with eczema
can get diaper rash too. But sometimes you take
off the diaper and it's pristine. Or you look
under the axilla...pristine. And those places,
I always tell the parents, you know, look at
your child. Look what the skin likes. It likes
moisture. Now, it may be more to do with the
microbial flora in those areas that's keeping
it so pristine. I don't know. But I will use
that as a teaching point to say, however you
accomplish hydration. The skin barrier with eczema
is leaky. Water escapes. Bacteria and allergens
get in. We need to help that barrier because
it's not as competent while they're having active
severe eczema. So how we incorporate a bath is
you bathe and... If you're in a bath long enough,
your fingertips get wrinkly, whether you're in
a pool, a river, an ocean. If you're in the water
long enough, your fingertips get wrinkly because
that's very thick skin, and you can sort of see
the hydration, but water is soaking in your whole
body. You just see it on the palms and soles.
Use that as a timer. If you're in long enough
for those fingertips to wrinkle, get out within
reason. It doesn't have to be so exact as that,
but within reason, get out, pat dry, and more
importantly, before they unwrinkle, moisturize.
The so-called "soak and seal." If you do that
and the parents find that bathing and soaking
and sealing once a day is best, wonderful. If
they tell me, boy, I did that and my child seemed
to do better when I bathe them once a week, soak
and seal, but I moisturize every other day. Wonderful.
I try not to be too dogmatic about how often
they bathe. Because number one, it's not easy
necessarily. Life happens. And that's another
guilt trip saying, oh, you must bathe your child
every day. And maybe it actually is not the best
thing for that child. Eczema is nothing if not
an individual disease. There are these bedrock
principles we're talking about. But then the
parents are the experts in their child's skin.
And they use these principles to sort of cobble
together an action plan. Yeah, I would agree
with that completely. I have in my mind, if you
can get a good moisturizer onto that kid two,
three times a day, I mean, I might be even asking
too much, but I don't really care about the bathing
principles. Although I think I've changed a little
bit in the sense that I don't know about Seattle,
but Bethlehem, and there's a lot of reasons for
it. It's a big wrestling community. We have a
lot of Staph aureus here. And people have looked
at it. It's a little higher than the normal what
you would expect. So for me, a lot of our patients
are colonized at least. Some of them are super
infected with Staph aureus. So for me, that mechanical
act of just getting some of that load off the
skin is useful. So I have found myself more than
not recommending once a day, short, five minute,
lukewarm, get out of there. And then very importantly,
to your point, moisturize. You got to soak and
seal. You got to get that moisturizer on. I don't
know. Does that jive with, am I okay doing that?
Oh, 100%. So to now feel the space to be honest
and open about my practice, I recommend bathing
once a day, soak and smear. Didn't want there
all of a sudden to be technical difficulties
and my mic was cut. So I wanted to make sure
that that was coherent with your practice. But
the point being is not one size fits all. But
yes, that's exactly what I do. And that's one
of the reasons I do it. And that also gets another
maybe... place we may or may not align is the
use of bleach baths um you alluded to them a
bit ago and i do recommend them um as a potential
adjunct um to treating and and the That raises
so many questions with, you know, some of our
parents have three PhDs. And so they're asking,
what's the mechanism? How does that work? What
happened? And, you know, the concentrations we
use in bleach baths don't even kill staff in
the water. But what they do is they are a non
-steroidal anti -inflammatory treatment, no matter
how counterintuitive that sounds, by putting
bleach in the bath. And so it matters how you
do it. You know, for me, the formula is half
a teaspoon per gallon. Take a regular bath. At
the end, I have them rinse off. get out, pat
dry, moisturize. I have them do it once to twice
a week, but if they're doing better on the days
after the bleach bath than the days before, they
can do it more often. And it just gets at that
idea. You know, Bethlehem, we... absolutely
have this Staph carriage issue that you alluded
to there. And I'll sort of describe for parents
that Staph aureus is like gasoline on the fire
of the eczema. It doesn't cause it, but it certainly
drives it along and then can get to a point where
there's a conflagration and you actually have
oral antibiotics, you have an infection. But
when it's just just carriage, you need to address
that as part of the treatment. And that's one
of the reasons that the bleach baths are so helpful.
Yeah. And I think one of the things you said
that's most important to call out is the need
to rinse off with fresh water after the bleach
bath. I have I've had some patients not do that.
And you get dry, probably drier than you would
be without the bleach baths from the chlorine.
Painfully, my two boys are swimmers and we're
in the middle of summer swim right now. And both
of them are developing xerosis ("dryness") from.
being in the water. One of them showers right
after he gets out of the pool, The other comes
home about 15-20 minutes later and is supposed to
shower. Most of the time he does but man even
good moisturizers when you're putting them on
that sort of cracked dry skin they can sting
and that's been an issue for my boys so i can
imagine what having moderate, severe, open, cracked
eczema skin, some of those products that we're
asking our patients to use, especially like a
steroid, topical steroid, where we know stinging
is going to occur. It must really be an issue
for them. So yeah, rinsing off as quickly as
possible and then moisturizing as quickly as
possible after the bleach bath, I find to be
very helpful and to mitigate that. Agree. So
how has your approach to systemic therapy for
your severe atopic dermatitis patients changed
in the last... five to 10 years. How's that for
a way? Changed a wee bit. Changed a wee bit.
Well, I'll just give you a sort of a very simple
way to describe how much it's changed. When we
did our first atopic dermatitis guidelines for
the AAD in 2004, we met for six hours in a hotel
and we were done. in 2014 took a little longer
still in 2014 so from 2000 when all we were just
talking about the topical calcineurin inhibitors
2000 2001 when they came out to 2017 there was
not a single novel molecule for atopic dermatitis
that came out there were me too topical steroids
and things like that but not a single novel molecule
in 2017 dupilumab (Dupixent) came out uh for adults
it's since been approved we've been one of the
sites of the pediatric trials for all the age
groups went down to 12 went down to six years
now down to six months of age a biologic injectable
medication depending on the age once a month
or twice a month uh for moderate to severe atopic
dermatitis the kind of kids we're talking about
patients we're talking about and it's 100% revolutionized
my my treatment because prior to 2017 what was
the only systemic medication approved for this
patient population oral systemic steroids. So
exactly what we don't want to use if we can help
it. So, and why is that? That's actually worth,
I was glad that you brought that up because I
was going to be going to start with that one.
So why, why don't we like that? Yeah, it's right.
It's seductively effective, isn't it? Good word.
It is just not a chronic intervention and atopic
dermatitis is a chronic intervention. Systemic
steroids chronically can have significant side
effects, bony impacts, infection, on down the
line. And I use the term seductive because we've
already described these families who are losing
sleep, getting infections, all sorts of things.
a day or two of oral steroids. And my goodness,
it's like a different kid. They're sleeping like
a baby. They are not infected. They are looking
like a million bucks, not itching. The problem
is when that course ends, whether it's five days
later or three weeks later, it's just going to
come rolling right back. Sometimes so-called
"rebound" - sometimes worse than it was before.
And so there are times when I've got a kid who
is so inflamed, head to toe, everything. stings
just like you said so the things we need to use
to recover uh are not there sometimes i will
have to use the steroids briefly to calm them
down so we can use the more sustainable therapies
so i i will not say that i never use systemic
steroids but but i try not to And prior to 2017,
that was it. That's all we had. We had non -steroidal
options like cyclosporine and methotrexate, but,
you know, those are pretty heavy-hitting medicines,
and I still use them too sometimes. But since
2017, we had for the first time an FDA -approved
non -steroidal intervention, systemic intervention
for atopic dermatitis. That was dupilumab, dupixin.
Since then, there are other biologics, tralokinumab,
lebrikizumab. nemolizumab - lots of "MABs" - all of
these "monoclonal antibodies" (MABs) that treat
eczema. There are small molecules, so -called
JAK inhibitors approved. So those are oral once
a day agents for moderate to severe atopic dermatitis.
So a whole different landscape. And so, yeah,
100 % different than I used to use five, 10 years
ago. If I came to your clinic. tomorrow as a
patient of yours, do you have sort of an a la
carte? And let's just assume I have severe, moderate
to severe atopic dermatitis that has been recalcitrant
to all the topical interventions we've mentioned.
Do you have sort of a a la carte go -to in your
mind of what you would start with and how you
would work from there? Yeah, I guess first of
all, if you came to my clinic tomorrow, I'd say,
I'm sorry, Andrew, you're way too old. I feel
like I'm 16, Rob. I'd have to send you down the
road. I'm so sorry. However, I take your point.
If a patient came to my... My clinic, a pediatric
patient, yes, indeed. By far, again, I'm a pediatric
provider, so this doesn't necessarily translate
to the first -line approach to adult patients,
but my first go -to is dupilumab. Why? It's been
around the longest, so we have the longest track
record. It's approved down to six months of age.
None of the others are. All the other systemic
medications, the youngest age of approval is
12 years of age. One of the oral JAK inhibitors
is approved down to two years of age in Europe,
but not in the United States. So I'm comfortable
using these things off -label other than dupilumab
when I need to. But to answer your question,
that is my first go -to. Don't need to check
blood tests to monitor it like we do some medications.
So even though it's an injection, which is never
a wonderful thing to hear for a pediatric patient,
that their treatment's going to be a shot. It
can be as little as once a month, as much as
twice a month. So it's not that frequent. We
have ways of making it more tolerable. So that's
sort of where I start. But then absolutely have
patients on all of those other medications. What
are some of those specific? interventions that
you mentioned or alluded to for the shots for
giving the shots what's uh what are some of your
tricks yeah but in terms of systemic medications
or oh just anything that makes the patient more
at ease with having or giving themselves the
injection oh gotcha yeah of course so um first
of all i'll sort of we'll kind of go through
sort of the mechanics of it so it's something
that's done at home So kids don't like shots,
period, but they also don't like going to the
doctor and getting shot. So we can reassure that
it's something done at home. Of course, then
the parents are the worried ones, not the kids,
because they're not always so thrilled about
that idea. But we talk about some really important
things to make it hurt less. Number one, the
medicine's got to be at room temperature, so
you've got to let it warm up, number one. Number
two, we always try to figure out a way so the
child's comfortable and feels like there's some
element of control, and a lot of times that's
a child hugging one parent if this family is
able to have two people give the shot at the
same time that's a luxury not all families have
but if they do one parent sort of or one one
helper hold the child while the legs are sticking
out on the other side and we can put ice for
about five ten seconds before to cool off the
surface and then give the injection you can also
Use Emla cream, numbing cream, for about half
an hour before. And then the ice. Those two things
can be done together. And then finally, you can
do all of those things. And then someone proximal
to the shot. So if the shot's being given, say,
mid -thigh, a little higher up on that same thigh,
you can sort of tickle or scratch or use a vibratory
device. There's something in pediatrics called
a Buzzy Bee" that literally is just a vibratory
device that you use to sort of stimulate that
skin proximal to the shot. confuses the pain
fibers such that it just doesn't hurt as much.
Yeah, that's exactly what we do. I might add
that I dole out lollipops like I'm a pro -diabetes
physician in the clinic. But I find that that
little burst of sucrose right before the shot
is given is a good distractor. But yeah, everything
that you just mentioned, I try to incorporate
into giving the shots. And I find that The vast
majority of patients are happier being able to
do that at home without coming in to see us,
disrupting their lives. And then when you add
to that the fact that the medicine works, it's
a real, I mean, it's as close to a miracle as
probably I've seen since Hemangeol for hemangiomas,
which is the first real game changer that I've
ever witnessed in medicine. So that's kind of
cool. The funny thing about Dupixent is - and
I don't know if it was hubris or because I was
a scaredy cat - but I would say it took it really
two years for me before I jumped on the bandwagon,
you know, to use it. I just, I didn't like the
idea that it was an injection. And I just didn't,
I couldn't get past the idea that, that a, my
topical regimen couldn't do it. That was probably
the hubris part of it. And then, geez, what is
this systemic medicine going to do? Is it going
to cause these people to grow flippers or horns?
And to your point, 18, 12, 6, 6 months. Geez,
okay, no labs necessary. And people are walking
into clinic that I saw just a couple months ago
with severe disease. They're now clear. You know,
it's amazing. And I have to give I have to say
I have to give my private practice physicians
a big hurrah on that one, because I think they
might be a little faster to go to those newer
medicines because the patients are seeing them
on the commercials, which we can argue are not
really helpful. But for in this case, they might
be. And then because those adults were getting.
Dupixent faster, sort of a trickle down. I would
hear about it and go, geez, I, maybe I need to
open my mind up to be a little bit more receptive
to using a systemic medicine like that. And geez,
that was five years ago. And now it's to, to
your point, it's our, it's our go -to for when,
when everything else fails and you need a systemic
therapy. It's pretty amazing. Yeah, I completely
agree. One thing I've always been interested
in, and I haven't really found anybody who does
this yet. But to me, mechanistically, it seems
like it works, would be if you had a patient,
especially one with severe itch, who came in.
And from your experience, how long do you give
Dupixent before you start to expect it to work?
Is there a number that you can kind of throw
out? Yeah, I'll usually tell parents that, you
know, two, three weeks they will start to see
some improvement. But if you look at sort of
the curves in the studies, it's a good two, three
months before they start to plateau out at their
peak effect. But I've had kids, and I think this
may also be a bit of the psychology of it, because
they come back and it has worked. And they're
like, the first shot, it worked after two or
three days. And maybe it did. But I think it's
also, finally, something has worked. And so the
mind sort of might change the time stamp a little
bit. But it's usually, you know, two weeks in
there, they're like, okay, I'm starting to feel
it. I'm itching less and my skin's less red.
Yeah, agreed. And so one of the things I always
thought was that, so sort of, okay, Dupixent
with its safety profile and lack of blood work
being not necessary to do blood work. Have you
ever used a JAK inhibitor to "bridge" them onto
Dupixent? And that's just something I haven't
seen anybody do, but it makes sense because as
I understand it, those JAKs are faster acting,
a little bit better maybe for itch specifically.
And could you get them? two three months bridged
on to do pixen and then have the pixen carry
the the rest of the way yeah absolutely i mean
we used to do that with cyclosporine, right? we
did it and it did work and it worked quicker than
methotrexate, six, seven weeks, eight weeks.
So we used to use cyclosporine to bridge patients
to a more sustainable therapy, still do sometimes.
And the theory behind that absolutely is right
with JAK inhibitors. JAK inhibitors, I have had
kids say literally a day or two, I'm itching
less. It's remarkable. The reason I don't is
because the folks in my office who work on prior
authorizations might fire me. So one new medicine
at a time for my crowd. Yeah, that's the practical
realities of not being able to do everything
we necessarily want to do for the patients. So
when Dupixent is not working in those rare cases
when it doesn't, how do you broach that with
the patient? Where kind of do you go after that?
Yeah, there's some interesting sort of discussions
on both ends of this spectrum. So the kids in
the question you asked, the ones who don't work,
where do we go? And then the kids for whom it
does work, what's the end point? So that's another
really sort of... unclear um discussion but with
regard to the question you asked i'll usually
say let's give it a good three months um exactly
for the reasons we talked about it that's sort
of when the curve starts to peak and if you're
just seeing nothing then like we talked about
before step back why um it works for most why
not this kid um and are they using it is there
another diagnosis do we need to think about all
those things great do that but let's say We got
the right diagnosis. They're using it appropriately.
It just isn't the right medicine. What do we
do? That's when, for me, the next step is typically
a JAK inhibitor. There are other, so getting
back to your word mechanistically, so Dupixent
works IL -4, IL -13. There are two new agents,
Tralokinumab, Lebrikizumab, which are IL -13
agents. I haven't necessarily... looked in that
direction because the mechanisms are similar.
That isn't necessarily proven that they wouldn't
respond, but I would generally think of either
Nemolizumab, which is anti IL-31, a different mechanism,
or one of the JAK inhibitors, which is a very
different mechanism. Are you finding that you
can get those accepted by insurance companies?
I'm striking out most of the time with those.
It's a struggle for sure. They have to be 12
or older. strikes a lot of my kids who are younger
than 12 because off -label almost never am I
able to. But I do have a number of kids older
than 12 on mostly JAK inhibitors because the
others are newer, but a few kids on Lebrikizumab
and Tralokinumab and a few kids on Nemo. And
either concurrently or separate from, what role
do you... I don't know if you know this living
in Seattle, but there is a thing called the Sun.
Now, we haven't seen it much in Pennsylvania
the last four weeks. How do you find that place?
Yeah, yeah. You got to look up, but it's there.
And so when you don't have access to 10 minutes
a day of sun, sometimes we'll use phototherapy.
Wow. Yeah, I know. Do you even use phototherapy
much these days? I do. I mean, we do a lot of
it, actually. Not a lot. The challenge for us
is we don't have a phototherapy unit at our hospital,
so we have to send them elsewhere. Now the University
of Washington is right here. Our adult colleagues
are right there, and they will treat kids to
a certain age, and it's sort of variable, but
definitely not younger than six. And so we don't
use it a lot. My challenges with phototherapy
are both logistical, insurance approval. The
frequency of the need having to go in so often
is a real logistical barrier for a lot of parents.
And then a lot of times it's a matter of the
kids I most, most want to treat are those super
inflamed kids. And oftentimes I have to kind
of calm them down before phototherapy can kind
of be, like we said, bridge them to the phototherapy.
But I do and I have and I will, just not often.
Do you ever use a medicine like Dupixent in combination
with phototherapy or is that taboo? Yeah. No,
no. I absolutely could do that. And I've used
Dupixan in combination with methotrexate and
other systemics. So I have done that. Yes. Yeah.
Yeah. We use phototherapy oftentimes with the
other systemics and usually with good effect.
One thing to your point about the just practical
nature of not coming in two to three times a
week for... It's only a couple of minutes, but
it's still just a nuisance. We've been very lucky.
And I don't know, maybe the insurance companies
did the math and they just figured out it's cheaper.
But we've been very good at getting at -home
units approved for our patients in this area,
way more than any other place I've ever lived
or worked. I don't know if that's a thing out
in Seattle, but they've been, you know, for $6
,000, you can... basically get a pretty decent
at -home therapy of course you have to have a
place to put it and it's usually in the living
room for for the family but um that's that's
really done wonders for for some of these kids
who need it yeah and i think you're right i have
a handful of kids with home units for sure and
i think it is i can't remember that study was
like after three months you're like paying it's
paid for itself the home unit so i think insurance
companies see that yeah what do you think dr
sidberry is on the horizon next couple years
what are we going to see Oh, boy. There's the
National Eczema Association, which, as you know,
is a wonderful advocacy group for patients with
eczema, families with eczema. I'd highly recommend
anyone listening to your program who's not visited.
I think it's nationaleczema.org or something
like that, but just Google "National Eczema Association."
You'll find it. It has a page, a research page,
and it lists all of the agents that are at
certain stages of approval. So clinical trials,
right? You got phase one, phase two, phase three,
all of the things that are phase three or beyond.
So that's... that's getting close to being a
medicine that the FDA can look at and approve
or not approve. And it is ridiculous. They're
like double -digit injectables, double -digit
orals, double -digit topicals coming down the
road. So I think additional MABS, as we've talked
about, will be on the way. Probably additional
JAK inhibitors. Some therapies that are sort
of looking through a little bit different lens,
maybe going back to the microbiome, some interesting
topical and systemic therapies trying to address
the cutaneous microbiome and its role that we've
sort of alluded to in sustaining and triggering
atopic dermatitis. So I think that's probably
where we're headed. Also, with all these medicines
we already have, including the ones that are
to come, sort of personalized medicine. That's
sort of the vanguard, where we're headed. perhaps
seeing the genetics of a patient and then matching
that to a certain medication if those studies
come out and so direct us. Or Emma Gutman, MD in
New York has done wonderful studies sort of characterizing
the so -called inflammatory signature of eczema.
And this patient with chronic eczema has more
of that cytokine or that cytokine. And boy, let's
not try that IL -31 because there wasn't much
of that in that patient's biopsy. Let's try the
other one. So things like... that i think are
where we're headed yes i i think they're doing
something similar for psoriasis out of Yale i
saw and um geez i maybe i'm speaking for both
of us i will not be sad uh the day that eczema
gets cured. It would be a wonderful thing for
everybody involved. Hopefully, we'll see that
in my lifetime as a practicing pediatric dermatologist.
But certainly, it's better to have eczema now
in 2025 than it was, as we talked about, just
five to 10 years ago. What a difference that
short amount of time relative to our careers
really leads to. So anyway. Great speaking with
you, Dr. Robert Sidbury, Chief of Pediatric
Dermatology at Seattle Children's Hospital. Really
do appreciate the time. It's just an amazing
resource to have you here and speaking to us
and our audience. Thank you so much for taking
the time. It's a pleasure. Thanks for having
me. Thanks for tuning in to this episode of the
Don't Be Rash Pediatric Dermatology Podcast.
I'm your host, Dr. Andrew Krakowski. Don't forget
to subscribe to our show on your favorite podcast
platform and check out don'tberash .org for more
information. A special thank you to our nonprofit
sponsor, the St. Luke's University Health Network
for making this episode possible. Until next
time, remember, keep calm and don't be rash.