Q&A: Management of Moderate to Severe Atopic Dermatitis in Infants and Young Children

Key Takeaways

• Consider atopic dermatitis in an infant who develops red cheeks or a rash that progresses to the arms and legs but spares the diaper and underarm areas and that is not relieved with emollient ointments.
• Food allergies are a common comorbidity in children with atopic dermatitis.
• Currently, the FDA has approved dupilumab (an inhibitor of the IL-4 and IL-13 signaling pathway) for children 6 months of age or older.

In this commentary, Robert Sidbury, MD, MPH, and Jonathan Silverberg, MD, PhD, MPH, answer audience questions from the recent Clinical Care Options webinar series titled, “Optimal Management of Moderate to Severe Atopic Dermatitis: Infants, Adults, and Everyone in Between!”

What are the signs of atopic dermatitis (AD) and food allergies in infants and young children?

Robert Sidbury, MD, MPH:
Typically, a baby starts to get little rashes on the cheeks at 3-4 months of age. This may occur during the transition from breastfeeding to the bottle or with the start of first solid foods. More often than not, the rash is due to continual wetting, drying, and irritant contact, and it can be a red herring. However, if a 4- to 5-month-old baby develops red cheeks or a rash that progresses to the arms and legs but spares the diaper and underarm areas, and the parents have experimented with different moisturizers or over-the-counter cortisone creams or prescription therapies from a dermatologist without any symptom improvement, AD is likely. To identify or rule out a food allergy in patients with AD, we do a detailed clinical history and, if compelling, then laboratory evaluation and an elimination diet.

Have you seen younger patients with AD develop more food allergies over the years?

Robert Sidbury, MD, MPH:
The incidence of food allergies has increased over time, and it is absolutely a common comorbidity in children with AD. Approximately one third of children with AD also have a food allergy, but that does not mean removal of the food allergy trigger will make the AD go away. This is difficult for parents to grasp, as they want to find the cause and make it go away so that the eczema goes away. A food allergy is usually only part of the problem.

Are there any additional novel agents or data that may change therapy for pediatric patients with moderate to severe AD?

Robert Sidbury, MD, MPH:
Of the many agents that we have talked about from a pediatric standpoint, the only one that is approved by the FDA for infants and young children (those younger than 5 years of age) is dupilumab. Dupilumab, an inhibitor of the interleukin (IL)-4 and IL-13 signaling pathway, was approved for children 6 months of age or older based on the results of the phase III LIBERTY AD PRESCHOOL trial. The trial showed significantly lower Investigator Global Assessment scores for patients receiving dupilumab compared with placebo. The prevalence of adverse events was similar between treatment groups. There also are two IL-13 inhibitors currently in phase III clinical trials for those with moderate to severe AD, lebrikizumab for adolescents and nemolizumab for children and adults. This is an extraordinary time, as for most of my career, there have been no new agents to discuss whatsoever. Now is really a good time to be taking care of patients with AD.

Jonathan Silverberg, MD, PhD, MPH:
Yes, we are in a golden era for AD, and it is amazing to see. I agree that lebrikizumab may become available for adults in 2023 or early 2024, and as often occurs, it will probably take longer to be approved for children. A new class of medications generating excitement is the inhibitors of the OX40-OX40 ligand signaling pathway; this pathway is known to drive Th2 effector cell differentiation. These inhibitors are starting to gain traction in later-phase trials in adults with AD, but there is still a lot we do not know about them. Several other drugs with new mechanisms are in development, and most probably will strike out, because that is the nature of drug development. However, I am hopeful that with these potential new therapies, we will get a grand-slam home run and totally revolutionize the way we think about this disease―so stay tuned.

Your Thoughts?
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