What are the challenges of pediatric atopic dermatitis amid winter?

This interview with Lawrence Eichenfield is the second of a 3-part discussion of pediatric AD. Click here for part 1. Click here for part 3.

Interview transcript (edited for clarity):

Contemporary Pediatrics:

What challenges are there for pediatric atopic dermatitis patients during winter months?

Lawrence Eichenfield, MD:

Pediatric atopic dermatitis patients, many of them have an innate dry skin tendency. And then atopic dermatitis itself is both revved up, it has more consequences with dry skin. Dry skin itself can cause itching that can exacerbate or initiate inflammatory eczema. Then once you have eczema, your skin gets inflamed, and you get more water loss, which dries out the skin, and that makes you both more inflamed and itchy, and there's a cycle that occurs. So, as we hit the wet winter months in many parts of the country, we not only get a drop in humidity outside but as people put on heat indoors that further causes an impact on humidity. More time indoors as well, which may be an issue but it tends to exacerbate atopic dermatitis, both from the dryness of the skin, and then there's a cycle that occurs from the winter months making people with inflammatory eczema more predominant.

While I just stated that cold temperatures and heat and low humidity exacerbate the eczema, we also get eczema flares from patients when they're too hot, and sweating. I think that can create an issue, like if you're in the Midwest or northeast, and it's the cold season, you may bundle up your kids when they're going outside and then you'll need to unbundle them when you go inside so that they don't overheat. So trying to get to a general, you know, temperate exposure can be helpful. But also probably the biggest intervention tried and true, is moisturizer to minimize the dry skin component both moisturizing after bathing, then moisturizing, if you're dry, despite a once a day application after bathing, for instance. Then, recognition of of inflammatory eczema is right up there, especially for my pediatric colleagues, many of whom know that the basics of moisturizer intervention is the number one thing we do. I put right with that recognition of inflammatory eczema because some of that can be managed with moisturizers, but many of the times they need more. They need an anti-inflammatory beyond what you can get with moisturizer alone.

Contemporary Pediatrics:

What treatments can be used when it comes to treating pediatric atopic dermatitis in harsher, winter months?

Eichenfield:

So let's say we've done our standard measures. We've advised about bathing practices, moisturizers after bathing, we've advised to recognize that dryness and change humidity might exacerbate. But if you have an inflammatory eczema beyond that, then we need an anti-inflammatory medicine. That's how I generally explained it to patients that when you see redness, you see the rashes, in severe cases, oozing or dryness and crust, all that as a manifestation of inflammatory eczema. When you see redness in the skin as well, that's inflammation. Then my discussion with my pediatric colleagues will be similar to my patients, "I got a broad set of things I can use that are anti-inflammatory, but they're somewhat tricky because the topical steroids are probably 70 different topical steroids." And they range from incredibly weak with very, very little side effect profile, to very strong. The difference between the weakest and strongest being over 2000 times. So the side effect profiles totally different, and then we have some nonsteroidals, depending upon age that are available and the newer nonsteroidals that are on the way that I think can really help us to manage inflammatory disease. You also want to get a sense of what you need to get the disease under control. And then the next thing which will probably be on follow up but also by taking a history the first time, is to get a sense of what's the course of the disease. After you get the disease under control, is it easy to maintain with just moisturizer maintenance? Or is it the type of eczema we're going to need sort of the asthma model of bring to it what we need to do to keep the disease under control and then to minimize itching, rashes, and flares.

Contemporary Pediatrics:

Can you speak to any trends regarding pediatric atopic dermatitis?

Eichenfield:

There's been a big trend over decades where we've gone from 4% or 5% prevalence of pediatric atopic dermatitis up to about 12% to 15% in the first few years of life. In the United States, pretty solid data, but very similar to other industrialized countries and there are these stories where patients move from more rural agrarian into a more industrial society, or in conversion of areas that become more industrial that atopic dermatitis prevalence goes up to that 12% or 15%. Even in adults, we have 7%, either persistence or prevalence of eczema in adolescent and adult years. I don't believe there's an increasing prevalence now, we've sort of leveled off over the past decade. I don't have necessarily the reasons for why we had that increase over decades. It's probably a mixture of maybe changing bathing practices where we're cleaner and we strip off some of the natural oils from the skin. It is partially, probably from pollutants in the air. We're more sophisticated about particulate matters, flaring atopic dermatitis, and known atopic dermatitis patients and there are some good groups looking at rates of atopic dermatitis based upon potential exposures. The translation and clinical practice of those issues is difficult to translate that into like interventions for patients, but it does explain the prevalence over decades, but also we're pretty stable at this point.

Eichenfield disclosed the following with Contemporary Pediatrics:

Board membership, Verrica Pharmaceuticals

Grants/research funding pending, Amgen, Johnson & Johnson

Stock ownership, Verrica, Forte (options for both)

Consultant/Advisor, Arcutis

Board, Arcutis

Investigator/Research grant, Arcutis

Eichenfield has served as a consultant, speaker, advisory board member or investigator for AbbVie, Amgen, Arcutis, Aslan, Bristol-Myers Squibb, Castle Biosciences, Dermavant, Eli Lilly, Forte, Galderma, Incyte, Janssen, Johnson & Johnson, LEO Pharma, Novartis, Ortho Dermatologics, Pfizer, Regeneron, Sanofi-Genzyme, Target RWE and UCB.