Severe Atopic Dermatitis in Children: Risks of Under-Treatment
Severe Eczema in Children: Balancing Treatment Risks and Questions About Growth
When a child has severe eczema, families may have questions about treatment safety and what could happen if the condition remains uncontrolled.
Atopic dermatitis, often called eczema, is a skin condition that can cause itchy, inflamed skin. In a Dermatology Times Expert Perspectives video series, dermatologist Eingun James Song, MD, discussed how he talks with families about treating severe atopic dermatitis in children. He also discussed early findings about the medication dupilumab and children’s growth.
Song is director of clinical research and co-chief medical officer at Frontier Dermatology. His comments reflect his approach to these discussions and the questions researchers still need to answer. (Source: Dermatology Times Expert Perspectives interview)
Considering the Risks of Uncontrolled Eczema
When discussing treatment with parents, Song considers both the possible risks of medication and the risks of leaving severe eczema inadequately treated. That discussion applies to all kinds of treatment, including creams, pills, and injections.
Children with severe, poorly controlled atopic dermatitis have a higher risk of certain related conditions involving the immune system. These include asthma, food allergies, and nasal polyps, which are soft growths inside the nose.
Song also pointed to a higher risk of conditions affecting mental health and behavior, including anxiety, attention-deficit/hyperactivity disorder (ADHD), and depression. These are associations, and they do not mean that every child with severe eczema will develop these conditions.
Growth is another question entering the conversation. Song said some children with severe disease may be smaller and might have grown taller if they had received treatment at the right time. More research is needed to understand whether treatment or better disease control affects growth.
For families and clinicians, the goal is to weigh the risks of treating too aggressively against the risks of not treating the disease enough. (Source: Dermatology Times Expert Perspectives interview)
How Biologic Treatments Are Explained to Families
One treatment discussed in the interview was dupilumab (Dupixent), a biologic medication made by Sanofi and Regeneron. Biologics are medicines made using living organisms or their components.
Song emphasized that calling a medication a biologic does not, by itself, mean it is safer or more dangerous than another type of treatment. The term describes how it is produced. Insulin and some vaccines are examples of products made using living organisms or their components.
When talking with families about biologics for eczema, he sometimes compares them to allergy shots because families may be familiar with those injections. He also acknowledged that the comparison is not exact.
What the Growth Findings Can and Cannot Tell Us
The findings Song discussed came from post hoc analyses. That means researchers looked at the data after the original studies had been completed, rather than designing those studies from the start to answer the growth question.
The studies were not specifically designed or large enough to establish height differences between children receiving dupilumab and those receiving a placebo, an inactive treatment used for comparison. For that reason, the findings cannot yet show whether the medication affects growth.
A study designed specifically to answer the question could be difficult to carry out. Song noted practical and ethical concerns, including the possibility of delaying an effective medication for children who need treatment.
Even so, future research could collect more information. Song suggested tracking height and weight, using bone scans such as DEXA, and looking at additional measurable signs in the body, often called biomarkers. One such marker is bone alkaline phosphatase, a substance in the blood associated with bone activity.
Researchers would also need to account for other factors that could affect growth, including the use of corticosteroid creams, sleep, and diet. (Source: Dermatology Times Expert Perspectives interview)
Is It the Medication or Better Disease Control?
Before drawing conclusions, Song said researchers first need to establish whether the possible growth benefit seen with dupilumab is real.
Another important question is what might explain it. The effect could be related to a particular medication, to a group of medicines that work in a similar way, or to better control of severe eczema itself.
Song noted that other treatments may also be studied as they become approved for younger children. These include IL-13 inhibitors, IL-31 blockers, and JAK inhibitors. These medicines act on different parts of the immune system involved in inflammation or itching.
He expects future clinical trials to collect more growth information. That could help researchers understand whether a particular treatment matters most or whether controlling the disease is the key factor.
Talking With a Doctor
Families considering treatment for a child’s eczema can discuss the possible benefits and risks of each option with the child’s doctor or dermatologist. A clinician can also help address concerns about symptoms, sleep, and growth.
Seek medical advice if a child’s skin is painful, bleeding, appears infected, or is changing quickly, or if you are unsure what is causing a skin change.
This article is for general information and is not a substitute for medical advice.
Sources
- Dermatology Times Expert Perspectives video series: interview with Eingun James Song, MD, on severe pediatric atopic dermatitis treatment and emerging dupilumab growth data.