Updates on pediatric dermatology

The field of pediatric dermatology has made numerous advances in the treatment of common childhood skin disorders. Pediatric dermatologists see a wide variety of patient presentations that can be exclusive to children, or may also overlap with adult populations. At the recent virtual 2020 American Academy of Pediatrics National Conference & Exhibition, Manasi Kadam Ladrigan, MD, a pediatric dermatologist in Rochester, New York, discussed pediatric dermatology in the context of COVID-19, then presented recently approved and upcoming treatments for various pediatric dermatological disorders. Her session titled, “What’s new in pediatric dermatology” is accessible to AAP members on demand through January 21, 2021.

Ladrigan began with a presentation on COVID toes that seem to preferentially affect pediatric patients testing positive for COVID-19. She then discussed the pathogenesis, current standard treatment regimens, and recent advances of 3 pediatric dermatological conditions: acne, hidradenitis suppuritiva, and hemangioma scars. She concluded with a section on other advances in pediatric dermatology.

“In spring of 2020 we all began seeing a larger number of young patients with acral perniosis,” reported Ladrigan. Although histologically identical to idiopathic perniosis, COVID toes seem to be a convalescent cutaneous phase reaction to COVID-19 infection. They appear as red to violaceous plaques on the toes and mid to distal digits, and seem to preferentially affect pediatric populations in wet and cold climates. Symptoms are often mild and do not usually limit activity.

Regarding pediatric acne, Ladrigan first discussed the importance of “tailoring their acne regimen to their skin type, their acne severity, and their lifestyle.” She also pointed out that the course of skin lesions, along with need, safety, and agents used for treatment vary with age in neonatal, infantile, early childhood, pre-adolescent, and adolescent acne.

Whereas gels and lotions are recommended for oily skin, creams may be suited for drier skin and retinoids should be avoided, or special new retinoids that are less irritating may be indicated. In addition to gold standards such as topical retinoids, benzoyl peroxide, and oral antibiotics, Ladrigan noted the efficacy of hormonal therapies such as oral contraceptives and spironolactone, especially for acne on the temples, jawline, or neck. Recently approved treatments for acne included clascoterone, a topical androgen receptor inhibitor; trifarotene, a new topical retinoid; sarecycline, a narrow spectrum tetracycline; and topical minocycline foam. Ladrigan also discussed alternative treatments such as bakuchiol for skin elasticity, tea tree oil for soothing, and witch hazel as a toner for dry skin. In patients with inflammatory conditions, scarring acne that does not respond to oral antibiotics and topical agents within 6-8 weeks, should often be given oral retinoids.

Ladrigan then transitioned to a discussion on hidradenitis suppurativa, a skin disorder characterized by a variable presentation from small comedones with minimal inflammation to large painful pustules, cysts, scars, and sinus tracts. Often considered an autoinflammatory condition, various etiologies mentioned included increased friction on the skin, abnormal microbiomes, and follicular occlusions. Loose fitting clothing, oral anticholinergics to reduce sweat, weight reduction in obese patients, and smoking cessation are recommended for initial treatments. Systemic therapies Ladrigan mentioned included oral tetracyclines and Bactrim, and antiandrogenic agents such as drosperidone and spironolactone. For patients with persistent resistant disease, Ladrigan noted extensive clinical support for the use of immunomodulator adalimumab as a second or third line agent.

For the final condition, Ladrigan discussed hemangiomas, which “can be devasting for patients” who spend “years looking for therapies to try to resolve the scars.” Because hemangiomas exhibit rapid growth between 1 and 3 months, Ladrigan emphasized early referral, preferably by 1 month of age, with propranolol treatment until 12 months. In addition to propranolol, Ladrigan mentioned topical timolol as an alternative treatment for uncomplicated thin, small hemangiomas referred early in their course.

Ladrigan concluded the session with a description of other recent advances in pediatric dermatology. Janus Kinase inhibitors have recently been shown to improve hair growth in patients with alopecia areata after 6 to 12 months, although approval from the US Food and Drug Administration (FDA) is still needed. Ladrigan also mentioned a novel treatment for umbilical granulomas, which starts with cleaning the area, then applying salt with a wet toothpick, and finally occluding the lesion for 24 hours.

Overall, Ladrigan covered a wide variety of pediatric dermatological disorders, discussing both established regimens, recent innovations, and future therapies.

COMMENTARY

Many clinicians fail to recognize that cutaneous disorders in children and adults have a major impact on quality of life and require carefully designed and at times aggressive therapy. Ladrigan emphasized the importance of adapting treatment to the child’s age, ethnic background, and skin color as well as their personal preferences.

In the next decade we will be seeing an explosion of new biologic, anti-inflammatory, antibiotic, and nonantibiotic agents for multiple disorders including atopic dermatitis, psoriasis, hidradenitis suppurativa, vascular anomalies, genodermatoses, and others. My prediction is that these innovations will alter our approach to the evaluation and management of skin disorders in kids, adolescents, and adults.

Over the last decade the FDA has pushed pharmaceutical companies (eg, Pediatric Research Equity Act, Best Pharmaceuticals for Children Act, Title V of FDA Safety and Innovation Act) to initiate early inclusion of children in studies of efficacy and safety of new medications under evaluation in adults that would also be relevant for pediatrics. This has accelerated the introduction of new agents for children and will require that we all follow pharmaceutical development closely.

—Bernard A Cohen, MD, section editor for Dermcase, professor of Pediatrics and Dermatology, Johns Hopkins University School of Medicine, Baltimore, Maryland.