Inflammatory skin disorders: Acne, psoriasis, and atopic dermatitis
The care of pediatric inflammatory skin disorders has evolved, but more slowly for some diseases than others. Acne vulgaris is now recognized as much more common under age 12 than previously, presumably reflecting earlier pubertal changes in our preteens. Over the past 30 years, therapy has evolved with the use of topical retinoids (still underused by pediatricians, considered a “practice gap”), hormonal therapy with combined oral contraceptives, and oral isotretinoin, a powerful but highly effective systemic agent for severe and refractory acne. Specific pediatric guidelines came much later, with expert recommendations formulated by the American Acne and Rosacea Society and endorsed by the American Academy of Pediatrics in 2013. Over the past few years, there has been a push by experts for more judicious use of antibiotics for acne (oral and topical) to minimize the emergence of bacterial resistance. There are unanswered questions as we evolve our care: How will the new topical antiandrogens be used? Will spironolactone become part of hormonal therapy under age 18? Will the insights on certain strains of Cutibacterium acnes being associated with worse acne translate to microbiome or vaccine-based strategies?
Pediatric psoriasis has suffered, being “behind in the revolution” of biologic agents because of delayed approval of any biologic agent for treatment of pediatric psoriasis in the United States until just a few years ago, and lags behind Europe and elsewhere in the world by almost a decade. Only this year have we expanded beyond one biologic agent approved for under age 12 and two for ages 12 and older, with other approvals expected including interleukin (IL)-17 and IL-23 agents. Adult psoriasis has been recognized to be associated with a broad set of comorbidities, including obesity and early heart disease, and there is now research on how children are at risk as well, with new recommendations on how to screen children with psoriasis, supplied first by PeDRA and then in the new American Academy of Dermatology-National Psoriasis Foundation pediatric psoriasis guidelines .
Pediatric atopic dermatitis (AD) is in its early years of revolution. In the 50-year period of our thought experiment, AD has increased in prevalence from 5% or less of the pediatric population to 10%-15%. Treatment of most individuals has remained the same over the decades: Good skin care, frequent moisturizers, topical corticosteroids for flares, and management of infection if noted. The topical calcineurin inhibitors (TCIs) broadened the therapeutic approach when introduced in 2000 and 2001, but the boxed warning resulted in some practitioners minimizing their use of these useful agents. But newer studies are markedly reassuring about their safe use in children.
Steroid phobia, as well as concerns about potential side effects of the TCIs, has resulted in undertreatment of childhood AD. It is quite common to see multiple children during pediatric dermatology office hours with poorly controlled eczema, high body-surface areas of eczema, compromised sleep, secondary infections, and anxiety and depression, especially in our moderate to severe adolescents. The field is “hot” with new topical and systemic agents, including our few years’ experience with topical crisaborole, a phosphodiesterase (PDE)-4 inhibitor; and dupilumab, an IL-4-alpha blocker – the first biologic agent approved for AD and the first systemic agent (other than oral corticosteroids), just extended from 12 years to 6 years of age! As dupilumab gets studied for younger children, other biologics (including IL-13 and IL-31 blockers) are undertaking pediatric and/or adolescent trials, oral and topical JAK inhibitors are including adolescents in core clinical trials, and other novel topical agents are under study, including an aryl-hydrocarbon receptor–modulating agent and other PDE-4 inhibitors.