Chapters Transcript Video Latest and greatest in acne, eczema, and warts Excited to be here and um, let me get my slides up as well. Um So I am very happy to be presenting to you today about the latest and greatest in Acne, Eczema and Warts. Um I have no relevant disclosures and any off label use of medications will be reported as an outline of our talk today. I'll review cases that highlight these three common conditions, treatment options that you have at your disposal and also additional new treatment options that your patients may ask about each of these topics. Could truly be their own separate 45 minute session. Um But I hope at the end of this talk, you have a few more tools to treat your patients with and my focus will primarily be on Acne and Eczema as there are some more new treatment options available for these conditions. And then in the last five minutes or so, I'll review some tips and tricks that we have for warts. So why start with Acne? First of all, it's incredibly common. About 85% of people between 12 to 24 years of age are affected and in the US alone, it affects about 40 to 50 million individuals each year with an estimated cost of $2.5 billion each year. And second of all acne can have a major psychosocial impact. Um We see here that the presentation and severity as well as the residual scarring and pigmentary changes that people experience can be highly variable and the level of distress in the patient may not correlate directly with acne severity. Um In some studies, patients have reported similar decrease in quality of life as those with other chronic medical conditions such as diabetes, chronic asthma, epilepsy and arthritis. Um patients can be embarrassed and upset by their acne and they might not bring it up during their visit. And so really as their primary point of contact within the health care system, you can significantly improve their quality of life by addressing their acne. And we know that our patients have access to a wealth of information online. Although the majority of skin care content, unfortunately, that they're accessing is not from clinicians and also not evidence based. Um We've seen many issues with contact sensitivities from various skin care products recommended by social media. So my hope is that by the end of the section, you're more comfortable with your acne treatment arsenal so that you can be the professional expert opinion. Um sort of first line for your patients in thinking about treatment. I find it helpful to understand the pathogenesis of acne acne is a disorder of the PLO sebaceous unit, which consists of the hair follicle and sebaceous gland and without getting too much into the weeds of this unit. There's four key components that factor into the formation of acne. One is follicular hyper keratinization and abnormal shedding which essentially forms commodo or clogged. 42 is increased production of sea bone which is influenced by androgens. Three is an imbalance of commensurate follicle, specifically a cab and acnes or sea acnes and lastly the inflammation and immune response which then results in inflammatory pules and pustules as well as possible scarring. Now, with this understanding of the acne pathogenesis, we can select targeted therapy to address specific components for follicular hyper keratinization, retinoids, benzyl peroxide, salicylic acid and azotic acid can help with this component of como formation for increased Sebba production. Since this is primarily driven by an oral contraceptive pills and spirinolactone can help here in addition to topical retinoids for the proliferation and imbalance of C acnes, the topical and systemic antibiotics as well as benzoyl peroxide are utilized and these options. In addition to salicylic acid can also help to target inflammation. Notably, oral ISOtretinoin is the only agent that counteracts all four major pathogenic factors that contribute to acne development. Now, taking these options into consideration, we have excitingly and hot off the press um from this year, new guidelines from the American Academy of Dermatology. This is an update from prior guidelines in 2016. And if you're familiar with the prior guidelines, you'll see actually that the classics remain tried and true. And so in this most updated consensus guideline, the strongest evidence and recommendations which are noted with the navy blue boxes on the right were for topical agents like benzyl peroxide, retinoids, topical antibiotics, although not as monotherapy and oral doxycycline. So um moving on to a case with these guidelines, what would you recommend for this 13 year old girl with primarily Como Donal acne? She was recently started on a custom treatment plan from an online company a month ago. Would you give the custom treatment some more time or start other topicals like azotic acid, salicylic acid, benzoyl peroxide, benzoyl peroxide, and tretinoin or tretinoin alone. From the recent guidelines, you can see that all the options that are listed are viable. Um Depending on what was included in the custom formulation. It's possible that it's also a reasonable first step, but we can often provide our patients more effective treatments for a fraction of the cost. My starting place for mild acne is typically a benzoyl peroxide 3 to 5% wash and a retinoid such as over the counter Adaline or tretinoin. I prefer the benzoyl peroxide wash because I find it's typically better tolerated in terms of dryness and irritation and can be used for the chest and back as well. And it has less issues with bleaching clothing. Um Compared to the Leon formulations, it's important to review the possible side effects in anticipated time to improvement since we know that it often takes 6 to 8 weeks before there's any notable change. And in terms of retinoid use, I find it helpful to review that it may cause dryness to the point where people will notice some scaling around the mouth and nose. And that moisturizing while using the retinoid doesn't decrease the efficacy. And so by setting these expectations and providing strategies to minimize the irritation, you can help patients have better outcomes because they're more likely to stick to the treatment plan. And although the algorithm has different options, my starting place is typically that combination of retinoids and benzoyl peroxide because I find it works better and this is also supported by data. So here's just one example, out of many reports in the literature on the increased efficacy of treating with both the retinoid and and the benzoyl peroxide, you can see on the left that the combination of a dline and benzyl peroxide was more effective than each component alone. And the photos on the right demonstrate that even in more moderate to severe acne, a combination retinoid and benzoyl peroxide alone can have an impact. Now, going back to the pathogenesis of acne, we can see why it works as well. Um highlighted here with the combination, you can actually target all four key components of acne formation. So for this patient case, my next step would be the combination of benzoyl peroxide and trin. Now on the topic of benzoyl peroxide, some of you may have heard in the recent news in March about the detection of benzene and benzoyl peroxide products. This report was produced by the same lab Vasher that previously reported on benzene and sunscreen products. You can find a lot of the information about the reports online, but it's helpful to note that the FDA has not yet recalled any of these products. The testing was also performed at high temperatures and it's hard to say what the absorption through the skin actually is because most benzene are absorbed through inhalation. Additionally, one potential conflict of interest that you should be aware of is that the president of valour just filed a patent for a method to prevent benzoyl peroxide from breaking down into benzene. So there may be a bit of a conflict of interest there. Um Currently, our department's recommendation is to not store the medication, hot environments to not use older expired products. And we recommend the wash off products more than the leon products. And overall, we're still monitoring for more updated information, but I just mentioned this in case you've received any questions about it as we know that our patients often search for information online. Now, what about for this 13 year old girl who has more inflamed papules on her exam and early evidence of ice pick scarring on her forehead. She has been on tretinoin cream and Clindamycin lotion for the past year with variable use of the benzoyl peroxide washes of these options. What would you do change her topicals by adding in benzoyl peroxide, increase the tretinoin strength or add oral options like doxycycline ISOtretinoin or combined oral contraceptive or a combination of topicals and oral doxycycline. In moderate acne, oral medications are included in the treatment algorithm with the different oral treatment options. A selection of the best next step is often nuanced and can depend on patient specific factors. For example, some patients really do not want to take systemic medications or there can be patient and parental hesitation to take hormonal treatment options. I would say that in general, my starting place for moderate acne is either triple topical therapy including um benzoyl peroxide, a prescription, topical retinoid and topical clindamycin or oral doxycycline. In addition to benzyl proxy and topical tretinoin. In some patients, I will also consider hormonal treatment options either instead of or in addition to oral doxy and of note doxy is actually listed as having a strong recommendation in the most recent 2024 guidelines. Again, for best success, I find it helpful to set expectations for possible side effects and time to improvement. If I'm using a hormonal treatment option, I find that it can take more time to see improvement, possibly 3 to 6 months. And with starting oral medications, there is um an opportunity as well to set the stage for what's coming next Um I don't like to keep patients on oral antibiotics for more than 3 to 6 months because of being a good antibiotic steward and trying to help prevent against resistance. Um And so for some patients, the oral antibiotics can help to decrease the inflammation and really give the optimized topical treatment some time to work. Um and also possible hormonal treatment some time to work and then for others, the oral antibiotics are potentially a bridge to ISOtretinoin. And so in this patient, I went for option F I added in benzoyl peroxide, increased her tretinoin strength and started doxycycline. Um This patient had monarchy about six months prior to her visit with me and her cycles were still irregular, which is why I did not consider hormonal options at this time. In terms of the hormonal treatment options um for individuals who are assigned female at birth, we can use oral contraceptive pills and or spirinolactone. Spirinolactone has been used for decades in this context, especially for adults. But I do need to report that the use in pediatric patients for acne is considered off label of the OCPs. There are three FDA approved options for acne listed here and there are some special considerations as well for transgender patients who are in the process of transitioning um for patients who are transfeminine or assigned male at birth and may be undergoing estrogen therapy. Spironolactone is an option for treatment, but oral contraceptives should be avoided as this may impact their other hormonal treatment for trans masculine patients who may be undergoing testosterone treatment. Spirolactone is not a rational option as it may counteract ongoing testosterone treatment and OCPs can be considered. However, this may not be considered an attractive or viable option for some patients as it can sometimes cause distress to be on what are considered to be more female hormones during the transition process. Um but it can help with acne triggered by testosterone. One additional update to be aware of is that in December 2021 the federal I pledged risk evaluation and mitigation strategy program went through a major overhaul. Um So with a lot of advocacy work, I pledge was changed from a gender binary system to one with more gender neutral language. And with these changes, patients are now classified based on their ability to become pregnant instead of male or female. Um I think that this is a step in the right direction, but admittedly, it's still a very cumbersome program at times and cultural humility is essential as we counsel on trans masculine patients through the process of still needing to get regular pregnancy tests in order to receive this medicine. Now, at this point, you may be thinking to yourself that these are all the same tools that you've had for years. Where are the latest and greatest. Um In this case, I would say that the greatest according to the evidence are still the tried and true classics. Um But I will review the newer treatments from the past six years focusing on either new active agents or novel formulations. Um And of these options, Clos Coone is the only true new innovation in acne management since retinoids were introduced about 40 years ago. Um There have been other recently approved acne topicals but excluded them if they're just novel combination formulations of already existing ingredients such as fixed dose benzoyl peroxide and tretinoin products. So, sac Cycline is a third generation tetracycline that was approved in 2018 for acne in patients nine and up. Um The main advantage is that it has a narrower spectrum of activity and has anti-inflammatory properties as well. Syin is a weight based dose at 1.5 mg per kilogram once daily and comes in 6100 and 100 50 mg tablets. When comparing Cyclin to the existing tetracyclines, there's no current head to head studies to evaluate if there's a difference in efficacy. However, there are some unique properties of syin that are noteworthy. Um Number one is that the other tetracyclines have greater activity against gram negative bacilli in the normal intestinal microbiome. Therefore, Cyclin has potentially less impact on the gut microbiome compared to the predecessors. And number two, cycline is less likely to cross the blood brain barrier. Um Number three is that there are low rates of photosensitivity and lastly, syin has an FDA approved label describing low propensity for antibiotic resistance. You may be saying that this sounds like a great and safe option. Why did I not mention it first for that earlier case of moderate acne where I started doxycycline and you may have guessed the answer. But one major limitation is the cost of the medicine. These are prices pulled from good Rx for a San Francisco zip code. But the estimated cost of a one month supply of cycline is about $1000 versus $13 for doxycycline. I have tried to prescribe syin and submitted prior authorizations for my patients who have not tolerated doxycycline, but I've had limited success. So for me until access is improved and cost is less prohibitive, I find myself not reaching for this option routinely. The next newer agent is minocycline 4% foam which is approved in 2019 for patients nine and up. This was developed to minimize the absorption and toxicity of systemic minocycline. Similar to the other tetracyclines is thought to have both anti bacterial and anti inflammatory properties and as a foam, um it has a high lipid content which supposedly allows for more drug movement through CB and into the affected sites. One of the possible advantages is less susceptibility to resistance. However, without comparative trials of this agent versus existing topical antibiotic agents, I haven't prescribed this really as an option yet because of the significant cost. As you can see here for the estimate of 1 30 g can the next new agent that we have is Trifero cream. This is 1/4 generation topical retinoid that was approved in 2019 for uses in age nine and up. Um We already have a number of topical retinoids. So why do we need another? Um Trifero is thought to have a more selective target in the skin. And with that, it's thought to be potentially less irritating, but the jury is still out on that if it is actually truly less irritating than its predecessors. Um And in my experience, I still haven't prescribed this yet because again, there's a substantial price difference, unfortunately, as highlighted here and so without a compelling reason to reach for trifero over tretinoin, I found that counseling patients through tips and tricks to make tretinoin more tolerable has been helpful. Um such as being able to use it with moisturizers. The last new medical agent I want to review today for acne is class coded around cream, as I stated earlier. This is the first acne medicine with a novel mechanism of action in about 40 years. It was approved in 2020 is the first topical treatment to target the hormonal arm of acne pathogenesis. And it's also the only hormonal treatment approved for use in males. The mechanism is thought to be competitive inhibition of the androgen receptor at the sebaceous gland. And when it's absorbed, it's quickly metabolized to an inactive molecule which minimizes systemic anti androgen effects. This is approved for treatment of patients. Ages 12 and up in the clinical trials, Basco had statistically significant improvement at week 12 compared to placebo and no systemic adverse effects were reported. Um The most common side effects noted were redness scaling and dryness and about 10% which was similar um to the placebo groups and in a smaller study where they applied 6 g. Or if you look down at your hand, essentially four full finger lengths of cream um to the face and trunk for two weeks, 7% had an abnormal hp. A access response assessed by a post Intropin stimulation test. However, this normalized within four weeks of stopping the medicine and there were no clinical symptoms of adrenal suppression observed in the study or in the phase three trials. My takeaway from this is that it could be a side effect worth considering if we're planning on applying CLOS coded to larger surface areas. Um But with all that being said, um CLOS coded is included in the recent guidelines as a conditional recommendation in the appropriate setting. But many of us are still figuring out how to best utilize it as a tool in conjunction with other topical therapies, especially since the cost is prohibited for many and to add salt to the wound for the pricing when you prescribe the cream. There's actually a note that the cream needs to be discarded within a month after opening to recap. I wanted to bring back this familiar framework that we reviewed previously. The highlighted names on the slide reflects the new treatments that we just reviewed. Trifero is a retinoid and works by addressing follicular hyper keratinization class. Coone is a first is the first topical that targets the hormonal arm of ACNE and primarily works by addressing se production and topical minocycline and oral cyclin are both antibiotics that address the acne's proliferation and inflammation to round out our discussion of medical management for Acne. What would you do for this 14 year old male with an onset, acute onset of this over his face. Would you start triple topical therapy with benzoyl peroxide, tretinoin and clindamycin start doxycycline, start clos coone or examine the remainder of his skin, especially the chest back and scalp. If you pick d this is a photo of his back, you can see that there are multiple monomorphic red brown papules and some very scant pustules suse over the back. He was itchy and further history revealed that this had all flared in the setting of finishing a Medrol pack for a flare of his eczema. His koh was positive and this was pitters sporm folliculitis. He ultimately improved with ketoconazole shampoo and a course of oral fluconazole. And although his case was more exuberant, we can see more mild forms of pittosporum folliculitis in conjunction with Acne. And it's worth considering if patients have an acute change in their acne as Melas furfur could be the culprit. In which case, an anti-dandruff shampoo such as ketoconazole may help in terms of when to refer to dermatology. These are all great reasons to refer a patient to see us if they have failed the triple topical therapy as we discussed or oral antibiotic treatments or if their acne flares after stopping the oral antibiotics. Additionally, if they have significant scarring nodule cystic acne, we can see them for a possible isotretinin and start and can also discuss injection of active inflamed cysts with intralesional steroids. And if their acne is atypical, and I also want to acknowledge that even though you're not familiar with the guidelines and they feel comfortable using all of these tools, some parents and patients may just want to hear these recommendations from a pediatric dermatologist and that's a reasonable reason to send them to us as well to recap acne significantly impacts quality of life and you can help patients by discussing it during their visits. Combination therapy works best for acne to address the different pathogenic factors and refer to dermatology of acne's refractory or flares after stopping antibiotics or if it is very severe after reviewing the new agents that are available. The main takeaway is that the tried and true treatments are still the major backbone of acne therapy and that although the new treatments are exciting, they're also very expensive and I'm rarely prescribing these for my patients at this time until they become more accessible. I hope that with this section, you feel empowered with evidence-based tools to help your patients with their breakouts. And we'll move on to our next topic which is atop of dermatitis or eczema. I want to credit my colleague, Doctor Nicole Kyler for kindly sharing some of her slides with me on this topic. And I hope at the end of this section is that you have a better understanding of the therapeutic ladder of eczema. Understand common reasons that topical treatments fail and become more familiar with the new treatment options available. So why focus on eczema? Again, this is a very common condition in the pediatric population with a reported prevalence across the world ranging from 0.2 up to 36% and about 50% of these patients with eczema are treated in the primary care setting. Um So you have a key role in the management of eczema as well. The most recent estimate for prevalence in the US is about 10%. Although longitudinal data suggests that this number is increasing, we all know that eczema has a major impact on quality of life for not only the patients but also their families, it can impact sleep even with mild disease and that sleep dis disturbance then translates into daytime drowsiness and poor academic performance. Children with active eczema are 50% more likely to have sleep disturbances and this can cause stress within the family unit. Um In a study of 11,650 mothers and their Children with and without eczema. It was found that mothers of Children with eczema were 40% more likely to report difficulty falling asleep, insufficient sleep and daytime exhaustion as if being a mom is not hard enough. Um And in addition to on sleep eczema contributes to significant emotional distress, social isolation, depression, and limitation of activities for both the patient and family members. Multiple studies in the literature highlight the wide ranging impact of eczema on sleep lifestyle changes, social disruptions, time loss from work, school performance, and financial and mental strain. And this impact on quality of life is often brought up in clinic. Our first case is a three month old that I saw in my first few months of being faculty. Um and I bring him up because this was a humbling case to never forget the fundamentals. So these photos are actually one month after I first met him. So it's one follow up. And you can see that he still has significant and diffuse involvement of pink red scaly plaques with significant overlying excoriations. It was striking how itchy and uncomfortable he was and his parents expressed significant frustration at how fussy he was at home and his inability to sleep. I was thrown off a bit by how this was so still so persistent despite the use of topical steroids as I had given them trim a 1.1% ointment at their last appointment and thought I had counseled about appropriate use and gentle skin care. They were moisturizing with Aveeno and using an unknown type of soap at this time. And because of the persistence and the interesting well-defined plaques over the abdomen, I ended up taking a wound culture and also a biopsy which ultimately showed findings compatible with eczema and the wound culture was positive for numerous staph aureus. Um And so because he was nearly erythrodermic at this visit with almost 80% body surface area. We started um Cephalexin and de bleach bath switched to just plain Vaseline as a moisturizer and provided more guidance and counseling on how much and how frequently they should use the triumph and alone. And this combination and more extensive counseling must have done the trick because this was just in two weeks. Um You can see that he improved significantly. Now his case highlights to me the four major pillars of eczema treatment. This graphic is busy but highlights the multiple factors that contribute to eczema and therefore the multiple potential targets for treatment. For me, the major categories that I think of are number one, the skin barrier, number two, the inflammation and altered immune response. Number three itch and number four, the bacteria or microbiome of the skin and many of our patients with more moderate to severe eczema or a bad flare like the patient. I just shared a full treatment plan requires addressing each of these options this brings us to the therapeutic ladder. Um Climbing the ladder step wise is not always or even usually appropriate. But it's helpful framework for thinking about therapeutic options at the bottom is gentle skin care, which helps to address the skin barrier and everybody gets that and above that are various topical treatment options, then phototherapy, then systemic agents at the top. So what do we mean by gentle skin care? It's challenging because many products that are branded for babies have additional plant-based ingredients or added fragrances. And they seem to have really excellent marketing teams that tout the natural formulations um not to malign any specific company. Um But here is an example of the inactive ingredients list in a product that's advertised as being fragrance free that many of my patients come with in with have spent a lot of money on as well. Um I typically recommend fragrance free products from these larger brands and in terms of cleansers, babies do not need soap all over just in the more commonly soiled areas. And in terms of emollient, my preference is for plain petrolatum ointment or Vaseline. It's important to tell parents that the original formula is best as the baby formula. The Vaseline also contains fragrance. Um ointments tend to work better than creams and if patients wish to stick with more natural products, might go to oils that have good results. And studies are coconut oil and sunflower oil. Children with eczema can develop overlapping contact sensitivity. So I try to go through and eliminate as many possible allergens or irritants in their skin care. After gentle skin care, our first step in the action plan for eczema often involves topical steroids. This is really the standard of care for mild to moderate eczema and helps to address the pillars of both inflammation and itch. Again, ointments are preferred over creams as the creams can sometimes sting on application and also contain some additional ingredients that can ultimately be sensitizing. Um I find it helpful to identify a few good starting points for your toolbox for the face. A good general starting point is hydrocortisone, 2.5% ointment or dec night ointment. And for the body trione 0.025% or 0.1% ointment, these can be applied twice daily as needed until the flare is clear. And if there's no response within 1 to 2 weeks, we need to assess why. Um in terms of side effects, the main risks of long term use are skin atrophy. But on the face, there's also a risk of peri oric dermatitis. And I would say that with the strength of the topical steroids discussed here. Um as sort of your go to options in your toolbox, the risk of systemic absorption to cause adrenal suppression is very low, but it's a risk with more potent topical steroids. Now, speaking of topical steroids, um as we discussed earlier, many of our patients and parents are on social media and you may have already received questions about topical steroid withdrawal. This is a controversial topic. But within board certified dermatologists, the thought is that it's primarily associated with prolonged and inappropriate use of moderate to high potency, topical steroids on the face and genital, fewer of the cases are reported in the pediatric population. And the presentation is typically different from the primary condition with burning being the primary symptom over itch and this is likely over reported in the lapus. And I've yet to actually see a true case of topical steroid withdrawal. More commonly. I see issues um with undertreat and then a subsequent flare of intrinsic eczema. And now this takes us to possible reasons for lack of response. Um A very common one that we see is inadequate use of treatment or undertreat sometimes in an effort to minimize the use of steroids patients and parents will stop treatment too early or use the medications too sparingly. This may have been the case with our first patient. Um and other possible causes for lack of response to topical treatments is if there's a secondary bacterial infection or colonization, which ties back to one of the four pillars that we discussed earlier and was also relevant for my patient. Um And additionally, there can be limited responses as well if the disease is too severe for the topical treatment or if there's an underlying allergic contact dermatitis, that's still active and flaring. And lastly, it's always helpful to not anchor and revisit. If eczema is truly the diagnosis of patients are not responding as expected. I would say that in general if you feel a patient's not responding, as you would expect with optimized, gentle skin care and low to medium potency, topical steroids. That would be a great reason to send to your friendly pediatric dermatologist. Here's another patient who is a two year old with a nearly lifelong history of eczema. Since the age of two months old, she has multiple small lichenified plaques over her wrists and dorsal feet. And mom reports that treatment with trione, 1.1% ointment helped but it flares right up after she stops. So how can we help to prevent flaring? I typically counsel parents that eczema is a chronic condition that will flare at times with various triggers. But the goal is to give them the tools to treat flares and to prolong the interval between the flares when flares occur in the same areas all of the time. Right. After stopping treatment, like in this last patient, we have few options for maintenance. For more mild disease, diligent skin care may be enough, but for more moderate disease, sometimes we add in low potency maintenance, topical steroids that are applied 2 to 3 times a week or we add in non steroidal options that can be used once daily without risk of thinning the skin. I typically don't reach for the non steroidal options for acute flares because one of the major side effects of the burning sensation on application and it can be hard to establish a skincare routine if the patient associates all creams with burning and discomfort. Some of the first non steroidal options that we had access to were topical costa neuron inhibitors or tacrolimus ointment and PCRM cream. These were FDA approved in 4001 respectively and they have no risk of atrophy or other adverse effects um compared to topical steroids and are a good option for areas of thinner skin. It's FDA approved for ages two and up. And as I mentioned earlier, the major side effect is the sensation of burning or stinging on application. And additionally, just to note since 2006, there's been a class block box warning on both tacrolimus and paninis for increased risk of malignancy, which sounds very scary to parents. But since then, there's been multiple long term studies looking at the safety of these medications and pediatric eczema patients um without any increased risk of malignancy compared to the placebo or control groups. Um And for my two year old patient, I had patient, I had the parents transition to tacrolimus ointment for her hotspot areas. Once we were able to fully clear the lichenified plaques with the topical steroid and that was effective for reducing the or increasing the time between her flares another non steroid tool that we have is cresol ointment, which is the PD four inhibitor. The main benefit of this is that it's FDA approved down to the age of three months old. However, the main downside which I hope this cartoon of Jack Jack will help remind you of is application site, pain and burning sensation, which is often a major limiting factor. I've had some parents who love it and swear by it. So I tend to discuss it as an option in patients. Lesson two where I want to utilize a non steroid maintenance treatment. I don't expect you to read through this right now, but I want to include it as an updated reference for you on the different treatment options depending on severity of eczema. The middle row consists of the maintenance treatment options and the lower row is what to do for flares. You can see that this is essentially the treatment ladder that we discussed just portrayed in a slightly different way. Um On the right, you can see that for severe eczema or for eczema that's significantly impacting quality of life and daily routine. It can be helpful to refer to dermatology to round out the discussion of topical treatment options. The newest topical medication that we have is ralli nib cream. This is a topical jack inhibitor and is approved for ages 12 and up. It does not have a significant burning or stinging sensation and is really quite effective at managing itch and decreasing inflammation. Um but because of concern for potential systemic absorption and the boxed warnings associated with systemic jack inhibitors. The recommendation is typically to use this for more limited areas. And um just to let you know of two new topicals that you may hear about later this year. Um that are coming down the pipeline, one is to pin Aro cream, which is already approved for adults with psoriasis and is currently in trials for eczema and Children 12 and up. And the other is Roulo cream, which is approved for psoriasis in kids, ages six and up. So now that we reviewed the topical options including possible new creams that you'll have in your arsenal moving forward. Um The next step on our therapeutic ladder is phototherapy. This is really a tried and true treatment option. But interestingly, the exact mechanism of how it works to decrease inflammation and completely understood. Um I've seen it work really well for patients with widespread eczema. It typically takes about 29 treatments to see improvement, which is about 10 weeks of time. Logistically, it can be really challenging since it's 2 to 22 to 3 treatments per week. Um And that can be hard to coordinate with both school and caregiver schedules. Children need eye protection while in the phototherapy unit and the equipment itself can appear frightening as well. Sometimes you can appeal for a home phototherapy unit, but typically insurance requires in office treatments for about a month before that can be an option. The major advantages of phototherapy are that it's a safe and cost effective option with no lab monitoring needed and it can be used in conjunction with topicals and most systemic medications. Additionally, in patients and families that want to avoid systemic treatments. This can feel like a more natural option which can be appealing. The disadvantages are that it's time consuming and inconvenient and there can be a delay in treatment response. This is a situation in which social determinants of health are really important as access and transportation can often be limiting. So, phototherapy isn't an option or there is insufficient response. The next step is systemic therapy. This is a 15 year old patient of mine that I actually just saw yesterday. Um and her exam, this photo is while on treatment with mota zone ointment, which if that's not in your irregular armamentarium of topical steroids, it's the same potency as trium 1.5%. So more of a moderate to strong topical steroid and because she also had prominent eyelid and facial involvement and persistently ified plaques in multiple areas that was impacting her ability to participate in activities, we ended up starting to pillow back for her and because of her busy schedule, phototherapy wasn't really an option. Um And so in this talk, I wanted to primarily highlight tools that you can feel comfortable using in your practice. But I will briefly review the systemic treatment options for eczema. So you know what else is available and what your patients may ask about. Um the first systemic as I alluded to is dupilumab, which really has been a game changer for eczema management since its initial approval in 2017 for adults. And with the most recent approval down to the age of six months in 2022 Dupilumab has changed the landscape for our patients with moderate to severe eczema. It's an IL four and 13 antagonist which ultimately works by decreasing th two driven inflammation and it does not cause general immunosuppression. In studies, more than twice as many Children achieved clear or almost clear skin and more than four times as many Children achieved its reduction with dupilumab plus topical steroids compared to topical steroids alone. And about three quarters of patients receiving dupilumab achieved at least a 75% improvement in overall disease. The dosing is age and weight dependent ranging from every 2 to 4 weeks. Administration, no lab monitoring is required but live vaccines should be avoided. I often will reach out to pediatricians if I'm thinking about starting D pillow so that we can coordinate timing of vaccines and do pillow a start and similar to the other new agents I mentioned for acne insurance coverage and costs are often issues but this is improving as a safety and efficacy. Evidence for DAB is so um appealing and compelling in terms of side effects. The most common reported side effects are injection site reactions, conjunctivitis and rarely a paradoxical head and neck dermatitis. These side effects are typically not dose limiting, but they are things that we monitor for as a conjunctivitis and head and neck dermatitis can often be bothersome. Perhaps most importantly, a major limitation to do piab treatment is the need for regular injection administrations. The medication can come as a prefilled syringe or an auto injector pen. Both of these options can be administered at home, but sometimes caregivers are not comfortable doing this. And I know that some of our patients have received their medications at their pediatrician's office. So I truly thank you for your time and collaboration in administrating this sometimes life-changing medication for our patients. Um The interval of injections is challenging since it's painful and there can be a lot of preinjection, anxiety and power struggles. And with the concerns around these frequent injections, we often get questions about what are the oral options that are available in terms of oral options. The conventional systemic treatment options that you may be familiar with are methotrexate, Cyclosporin. I would say that because of the side effects, lab monitoring and the slower time to onset with methotrexate. I find myself not really using this as much because we have better targeted treatment. Now, um Cyclosporin definitely still has a role in the therapeutic ladder though, since it's very fast acting and I think of it as the bridge to other agents. When we have to quickly decrease inflammation, the role of cyclosporin may change in the future though, depending on the availability of newer agents like Jack inhibitors, which also have a fast onset. So speaking of Jack inhibitors, as of 2022 there are two FDA approved Jack inhibitors for severe eczema in patients 12 and up aroy nib and pait in comparisons between DPI and aroint and U pait. The higher doses of the Jack inhibitors were more effective in treating eczema than dupilumab. But the lower doses were either equal or inferior to dupilumab. Both of these options require lab monitoring. These are the official recommendation from a package inserts but typically I get baseline labs then monthly for the first three months, then every three months. So while it is overall less pokes than do pillow A, it's still not a needle free option. And as you, as you may have guessed from the lab monitoring required the side effect profile for these medications look definitely less favorable than Dupilumab acne is significant and occurs in up to 16% of patients in addition to the real increased risk in infections as well. Additionally, there are black box warnings for Jack inhibitors. Although notably, the data comes primarily from adults with R A and other comorbid conditions. There's no evidence to date of the above and otherwise healthy pediatric patients with eczema. But the risk profile is more significant Um So to me, it still remains second line. In most cases, I have used them in less than a handful of my pediatric patients for eczema so far. And of course, with any systemic medicine, the question of how long to continue comes up, I'll be honest that the data on this is still limited about best practices regarding how to ta taper off of these medicines. Um because eczema is a chronic condition and we can't really expect a cure. Um But I do consider and discuss tapering options of the skin as well controlled or clear for about a year and one major systemic option you may have noticed missing is systemic steroids. This is from the guidelines for management of at topic dermatitis published in 2014 and in my opinion, is a bit understated even we often see rebound flares after short courses of steroids or you may even see pitters Sporn folliculitis as well. Um and prolonged courses have significant negative impacts on immune function behavior and growth. So with the current treatments that we have available, please don't use systemic steroids for flares to summarize treatment. Selection is patient centered depends on disease severity response to treatment and feasibility of the treatment and being patient centered. The fundamentals of gentle skin care and an eczema action plan including treatment for flares and maintenance. Topicals are still tried and true. Dupilumab is an approved safe and effect option for Children six months and up and excitingly, treatment options for eczema are still evolving. The topical and systemic JCA inhibitors are currently the newest treatments, although their side effect profiles are currently less favorable compared to Dupilumab. And with the current options available, systemic steroids are not indicated for eczema. Now, in our last five minutes, I'll share some cases and review some treatment options for warts. Um You may think that this distribution of time is a bit odd but as highlighted by this recently published review of pediatric warts, there has been little change in the last 20 years in the evidence based. Um similar to the foundational topical treatments for acne eczema salicylic acid and cryotherapy are the mainstays of treatment for warts. It's still worth reviewing though, as some studies show a prevalence of 22 to 33% in school age Children and warts can be embarrassing, painful. Um they can cause social stigma and this can all drive um desire for treatment in terms of treatment options. Um Some warts can spontaneously regress even without treatment. Um Sorry, there's one slide, I think that's a little sorry, one of the slides got deleted. But um in terms of treatment options, some warts can spontaneously regress even without treatment as I was mentioning. Um there is evidence that suggests that by understanding the different HPV strains causing the warts, we may better understand which warts are more likely to do well with the watch and wait approach other destructive treatment options include over the counter salicylic acid cryotherapy with liquid nitrogen intra immunotherapy and off label use of treatments such as Trent, non inycum compounded, topical safir and um compounded five fluoro and salicylic acid. Um I would say that my approach is to try and combine treatments typically with salicylic acid and cryotherapy plus or minus intralesional can if possible. And warts are really stubborn and can persist for a very long time. So having patients do home treatments is a very helpful first step for our first case, this is a three year old that was initially treated as having moles of keratin. So she initially presented on the left. Um And after keratin treatment, um unfortunately, these were warts, not molluscum. And so when I saw her, she had actually developed these brain warts and based on her age and poor tolerability of cryotherapy, we opted for salicylic acid treatment at home and you can see that she got some initial inflammation with the salicylic acid and the larger ring warts ultimately improved over a course of six months. So six months later is the photos on the right. Um But she still had some of these stubborn smaller wars. So we ended up prescribing her um off label compounded five fluorouracil and salicylic acid, which works quite well for a skin. This is another six year old that I saw with multiple warts on the hands. And um I had reached for five fluorouracil compounded with salicylic acid first for him because he had so many warts and he had significant trauma from prior prior uh cryotherapy treatments. It's very cheerful the minute you walk into the room. Um, but you can see on the right that he's had more inflammation, irritation from these topical treatments, which was actually also causing him a lot of discomfort. So we ended up decreasing the frequency of the topical treatments and starting treatment with intralesional can antigen. Um One benefit of intralesional immunotherapy is that there is a thought that by treating one or two warts, you can actually still get distant immune response to the non treated warts as well. And I typically do these injections every 4 to 6 weeks. But many patients find that the one or two pokes with the intralesional immunotherapy is less painful than multiple rounds of freezing for every single wart. Um I feel like I have to end on a more positive success case. Um since wars can be so stubborn and persistent. Um But this is a 12 year old who had undergone crowd therapy for this very large wart on her knee, um or for a large wart on her knee and she subsequently developed a very large ring wart. Um and she also has multiple warts on her hand. Um And we ended up treating her with intralesional candida. So on the left, this is after four treatments with intralesional can plus cryotherapy and salicylic acid Um And at that visit, we decided to add in the compounded five flour and salicylic acid. And this is six months on the right after starting the compound in medicine and after a total of seven injections. And so she was very happy to have graduated from our clinic. So the main take home points for warts are that they often require multiple rounds of treatment and multiple modalities. Um Sometimes it really feels like you're throwing the kitchen sink at them. But things to try first. Uh before referring to us are home salicylic acid treatment and in office cryotherapy. And just to keep in mind that it really can take months and months to have an improvement. Created by
