Use of Dupilumab in Pediatric AD
Expert dermatologists review the use of dupilumab for treatment of pediatric AD, and how topical and injectable medication can impact a patient’s lifestyle.
Brittany Craiglow, MD: Let’s talk about dupilumab. This has been a major breakthrough in dermatology. We’re going to look back and identify it as 1 of the biggest things that’s happened in 20 years for our patients. It’s approved for ages 6 months and up, which is exciting. Tell me about your experience with it. When do you start thinking about it? Is this a patient who might warrant dupilumab?
Angela J. Lamb, MD: Yes. Based on the lifestyle and the body surface area involvement, I’d seriously consider it. From an integrity standpoint, it’s always important to try some topicals and adjust the skin-barrier protection first. If somebody is coming to me—unless they’re completely covered and miserable—there’s no way they’re ever going to be able to apply topicals or even barely apply moisturizers because of the amount of involvement. If it’s my first visit, even if I think that might be in their future, I’ll see how clear we can get them and what we can do for them. I want them to buy into the fact that even with dupilumab, you’re still going to have to use your moisturizers twice a day. You still have to wet your skin every day. That that’s a big piece of this. These medicines are game changers. I love them. But because atopic dermatitis tends to be so chronic, I don’t want people thinking that they’re going to have a medicine—a pill, an injection—and then they’re clear and can do whatever they want to their skin.
Barrier protection is key. It’s important. There are some breakthrough areas. There’s going to be that resistant patch. You’re going to make it so that that resistant patch is gone by applying your moisturizer twice a day. As annoying as it is, I want them to accept that this is a chronic disease, and we’re going to have to manage it. Some of that is going to involve not just an injection every 2 weeks or every month. It’s going to be about how you take care of your skin.
Brittany Craiglow, MD: Yes, because you can’t escape your genetics in that barrier. It still needs support. It’s not the time to use fancy cream at your favorite store. That’s hard, especially for teenagers. They want to do things that their friends are doing. Acknowledging that, I get that you want to use X, Y, and Z, but this may put us back to where we were previously. Maybe we can talk about injections and kids, because dupilumab is an injection. Nobody likes shots, but kids really don’t like shots. How do we navigate that with our patients? What are some things we can do to make that easier for them?
Angela J. Lamb, MD: We always tell patients to leave the injection out 45 minutes to an hour because it’s more viscous. Also, I recommend an ice pack before, but be careful not to leave it on too long. A little ice pack will soothe the area and get it ready for the injection. Those are some of the main ways I help people manage that. I find that my adult patients have more needle phobia. Kids tend to be OK. They get along. They jump on board. The adults are like, “Wait, hold on.” They have some real anxiety, some real needle phobias. Some can’t tolerate it, unfortunately. I’ve never had that with kids.
Brittany Craiglow, MD: Yes, it’s infrequent that it’s a deal breaker. That bit of discomfort for a short time vs all the time that you’ve been spending taking care of your skin—that goes a long way. For young children, the injection is monthly. So 12 shots a year is not a ton. Going back to what you were talking about, you’d try topicals in this patient first. It’s important to note that sometimes we see a patient who looks like they’re headed for systemic therapy, but it’s because they’ve never been treated appropriately. Sometimes I’ll say, “We’re going to use this medicine called triamcinolone.” And they say, “I’ve had that before.” First, how big was the tube you had? Maybe they had a 15-g tube when they have 20% body surface area. And how did you use it? For a few days here and there?
An important thing to understand, especially for pediatricians, is the way we use topical corticosteroids and atopic dermatitis. It’s OK, and you’re not going to cause a problem doing this, but you need to use enough and use them for long enough. Give the patient a 1-pound jar of hydrocortisone 2.5% or triamcinolone, and have them do it twice daily for 2 weeks straight, even if they’re better. I tell patients think about it like a fire that you want to put out. Pediatricians should feel empowered. Even among health care providers, there’s this topical steroid thing. It’s not just among parents. But when you use it appropriately, it’s safe and can be a great option for patients. Once you put that fire out, people do better.
Angela J. Lamb, MD: They’re good with their barrier protection after that. I’m sure you know the literature, especially before some of these newer medicines came out. Good barrier protection works. I had a patient who was a child of a physician, and I wanted them to get the skin wet every day and use petroleum jelly with occasional topicals. She was like, “He’s cured.” I took the time to explain how you take care of your barrier using a cool-humidifying room when you have atopic dermatitis. There’s been a lot of literature about that. Sometimes we have to convince people that it’s that easy. A caveat is that for many patients, that doesn’t work. We’re talking about dupilumab. We’re talking about how I don’t want to give the impression it’s that easy. For some, it is. It’s hard to know until you take the time and write it down and do solid patient education. Then they buy in. They see that they can do this, and maybe I don’t need that medication.
Brittany Craiglow, MD: A lot of dermatologists use an eczema action plan, like an asthma action plan. That’s something that pediatricians could certainly do. Maybe for those who don’t have as good access to dermatology or are interested in treating more themselves. It’s an easy thing. This is what you do when you’re flaring. This is all the gentle skin care stuff. The simpler we can make it, the better. Try not to do multiple topicals if you can get away with 1—maybe 2 if you need a little higher potency for the body and lower for the face. Patients like to have that plan, and it seems more manageable when it’s kept simple.
Transcript edited for clarity
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