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REVIEW OF CURRENT LITERATURE
Year : 2022  |  Volume : 23  |  Issue : 2  |  Page : 101-104

Hot topics in paediatric dermatology


Department of Dermatology, Venereology, and Leprology, Postgraduate Institute of Medical Education and Research, Chandigarh, India

Date of Submission01-Aug-2021
Date of Acceptance10-Aug-2021
Date of Web Publication30-Mar-2022

Correspondence Address:
Dr. Rahul Mahajan
Department of Dermatology, Venereology, and Leprology, Postgraduate Institute of Medical Education and Research, Chandigarh - 160 012
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijpd.ijpd_119_21

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How to cite this article:
Thakur N, Mahajan R. Hot topics in paediatric dermatology. Indian J Paediatr Dermatol 2022;23:101-4

How to cite this URL:
Thakur N, Mahajan R. Hot topics in paediatric dermatology. Indian J Paediatr Dermatol [serial online] 2022 [cited 2022 May 21];23:101-4. Available from: https://www.ijpd.in/text.asp?2022/23/2/101/341457




  Evaluating the Efficacy of Telemedicine in Atopic Dermatitis Top


We hereby review a retrospective cohort study conducted at Sao Paolo, Brazil, where 57,832 patients were waiting for an appointment with a dermatologist.[1] The primary objective of this study was threefold; to assess what extent is it possible to manage patients of atopic dermatitis (AD) with primary care setting, avoiding undue pressure on specialists, to assess the diagnostic accuracy of telemedicine, and to determine the frequency of AD in the study population. The data of the patients were collected by a trained healthcare worker, and the details with photographs (three each with different views and angle per lesion) were stored in a mobile application with only dermatologist recruited in the project having access to the data. If the photographs were of poor quality, then the patient was directly referred to a dermatologist for face-to-face appointment. In patients with good quality photographs of their skin lesions, a probable diagnostic hypothesis was made and they were advised one of the following three options; in-person dermatological visit, biopsy of the lesion, and in-person visit to a dermatologist with histopathology report, or visit to a primary care physician with recommendations for diagnosis, investigation, and management of the dermatosis. Of the total patients, 54% of patients participated in the teledermatology project, and 5.3% of whom received a diagnosis of AD. Of all the lesions photographed, 3.7% of patients were of AD. The teledermatologist referred 28% of cases to in-person dermatologist, 72% cases to primary care physician, and only four cases were advised biopsy. The mean waiting time reduced to 6.7 from 15 months. Telemedicine was most effective in adolescents (13–19 years) and adults (20–59 years) and was used in the management of disease with general physician in 68% and 77% of cases. Intermediate results were noted in children (3–12 years) and adults more than 60 years (54% and 57%). It was least effective in children aged 0–2 years (43%). There was 84.4% match between teledermatologist and in-person dermatologist which increased to 90.8% and 95.4% if atopic skin conditions and all eczematous disorders were considered together.

The relevance of this study lies in the fact that in time of COVID-19 pandemic where in-person doctor visit is scarce, telemedicine can play an important role in the management of patients. The COVID 19 pandemic causing delay in consultation by months in some cases, the diagnostic window period being missed leading to diagnosis of disease in their advanced stages. It is important to note that patients with poor photographs of the lesion were sent directly for an in-person consultation stressing the fact that a good-quality photograph is important for a fruitful session of teleconsultation for a dermatological patient. In this study, there were trained healthcare workers to take photographs of the lesions, whereas in our setup, the patient/attendant takes the photograph of the lesion. Due to lack of proper knowledge regarding proper photograph of the lesion and nonavailability of good camera phones with all the patients, the outcome of the teledermatology becomes a challenge.[2] Privacy of the patient is also an important determining factor which needs to be considered as teledermatology requires the patient to share photographs of sensitive areas of the body. This can lead to hesitancy in the patient and also requires the physician to be cautious.[3]

Out of all the dermatological patients, this study assessed the outcomes in only AD patients, which is not the case in the pandemic where patients with all types of dermatological conditions need to be seen. Hence, only the outcome in AD in this study cannot be extrapolated to outcome of teleconsultation in dermatological practice combined with challenges of the necessity of a good photograph, good camera phone, and most importantly a good internet connection on both sides.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.


  References Top


  1. Giavina-Bianchi M, Giavina-Bianchi P, Santos AP, Rizzo LV, Cordioli E. Accuracy and efficiency of telemedicine in atopic dermatitis. JAAD Int 2020;1:175-81.
  2. Gupta R, Ibraheim MK, Doan HQ. Teledermatology in the wake of COVID-19: Advantages and challenges to continued care in a time of disarray. J Am Acad Dermatol 2020;83:168-9.
  3. Goldberg DJ. Digital photography, confidentiality, and teledermatology. Arch Dermatol 2004;140:477-8.



  A Phase 2, Open-Label Study of Single-Dose Dupilumab in Children Aged 6 Months to <6 Years with Severe Uncontrolled Atopic Dermatitis: Pharmacokinetics, Safety, and Efficacy Top


We review a Phase 2 multicenter cohort study in which dupilumab was studied in children for its safety, efficacy, and pharmacokinetics.[1] Dupilumab was given to 40 children of two age groups with disease characteristics consistent with severe atopic dermatitis (AD). Younger age group was children between 6 months and 2 years and older were between 2 and 6 years. In each group, 10 children were given 3 mg/kg of the drug, and subsequently, the other 10 children were given 6 mg/kg. The response was noted at 3 and 4 weeks. Primary end points were to study the concentration of the drug in serum over time and pharmacokinetic parameters including emergent adverse events. The secondary end points were incidence of serious adverse events and severe treatment-related adverse events along with change in different subjective and objective scoring parameters. The drug exhibited nonlinear, target-mediated pharmacokinetic behavior. The serum concentration of the drug was higher with 6 mg/kg as compared to 3 mg/kg dose in each age group. Lower serum concentration of the drug was observed in younger patients than in older patients for the same mg/kg dose level due to a faster clearance, per kilogram weight in smaller patients. The signs and symptoms at 3 weeks measured by the area of the eczema, severity index, AD scoring (SCORAD), SCORAD visual activity score for sleep and itch, and caregiver reported peak pruritus NRS score improved in both age groups with both the doses, with better results in cohort of older children particularly in the 6 mg/kg dose groups. The efficacy was seen to wear off at 4 weeks, to a greater degree in 3 mg/kg group. The safety profile in children was comparable to children >6 years, adolescents, and adults.

The relevance of this study lies in the current scenario of dupilumab being approved for treatment in children above 12 years of age. This Phase 2 trial categorically studied the efficacy, safety, and pharmacokinetics in smaller children. The importance of this study also lies in the fact that children with AD have other atopic conditions, each having different medical management; hence, dupilumab may serve as a drug that covers the entire spectrum of AD in a single patient.

There were no reports of conjunctivitis in any of the patients in the present study with 40 subjects. However, a meta-analysis in adults on the adverse effects on dupilumab had shown high risk of conjunctivitis (relative risk [RR] 2.64, 95% confidence interval [CI] 1.79–3.89).[2] There was also high risk of headache (RR 1.47, 95% CI 1.05–2.06) in adults which also needs to be looked in children.[2] Another issue regarding dupilumab therapy is compliance/persistence with the therapy as AD is a chronic disease requiring long-term therapy. There are no such studies in children; however, in a study to assess persistence of adult patients with AD, it was seen that the persistence with the drug at 6 and 12 months was 91.9% and 77.3%, suggesting patient satisfaction with efficacy and adverse effects.[3]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.


  Reference Top


  1. Paller AS, Siegfried EC, Simpson EL, Cork MJ, Lockshin B, Kosloski MP, et al. A phase 2, open-label study of single-dose dupilumab in children aged 6 months to <6 years with severe uncontrolled atopic dermatitis: pharmacokinetics, safety and efficacy. J Eur Acad Dermatol Venereol 2021;35:464-75.
  2. Ou Z, Chen C, Chen A, Yang Y, Zhou W. Adverse events of dupilumab in adults with moderate-to-severe atopic dermatitis: A meta-analysis. Int Immunopharmacol 2018;54:303-10.
  3. Silverberg JI, Guttman-Yassky E, Gadkari A, Kuznik A, Mallya UG, Mastey V, et al. Real-world persistence with dupilumab among adults with atopic dermatitis. Ann Allergy Asthma Immunol 2021;126:40-5.



  Efficacy and Safety of Dupilumab with Concomitant Topical Corticosteroids in Children 6–11 Years Old with Severe Atopic Dermatitis: A Randomized, Double-Blind, Placebo-Controlled Phase 3 Trial Top


We review a double blind randomized placebo controlled trial, involving 367 children between 6 and 11 years with severe atopic dermatitis to study the safety and efficacy of dupilumab. The patients were divided equally into three groups who received weight tiered dupilumab (100 mg/200 mg) 2 weekly, dupilumab (300 mg) 4 weekly irrespective of weight, and placebo. Both the regimens of dupilumab showed statistically significant efficacy with respect to improvement of signs and symptoms, including sleep and quality of life. The IGA0/1, eczema area and severity index (EASI) 75, LS mean percentage change in EASI, EASI 50, EASI 90, scoring atopic dermatitis, and peak pruritus NRS (≥3, ≥4 points improvement) showed improvement at 16 weeks after therapy with dupilumab and the optimal doses for safety and efficacy were 200 mg two weekly in ≥30 kg and 300 mg four weekly in ≤30 kg child. Both these dose regimens maintained higher blood trough levels. Conjunctivitis and injection site reaction of mild–moderate intensity were the two treatment related adverse effects noted which resolved during the study. Dupilumab group had lower skin and herpes viral infection indicating its effect in maintaining skin integrity.[1]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.


  Reference Top


  1. Paller AS, Siegfried EC, Thaçi D, Wollenberg A, Cork MJ, Arkwright PD, et al. Efficacy and safety of dupilumab with concomitant topical corticosteroids in children 6 to 11 years old with severe atopic dermatitis: A randomized, double-blinded, placebo-controlled phase 3 trial. J Am Acad Dermatol 2020;83:1282-93.



  Effect of Propranolol Exposure during Infancy on Growth and Development in Children Top


We review the article of propranolol effect on pediatric growth and development in patients of infantile hemangioma. This study prospectively examines first year growth parameters, developmental milestones, and guardian satisfaction in a total of 185 children treated with propranolol. WHO Z-score was used for comparison of growth parameters such as weight for age, body mass index (BMI) for age, and weight for length. Developmental milestones, treatment efficacy, and guardian satisfaction were assessed retrospectively using questionnaire. Observers also measured growth hormone levels of a small cohort of treated infantile hemangioma and age-matched controls. Patients were divided into two cohorts based on the presence or absence of comorbidities.[1]

Anthropometric data showed that both cohorts had WHO Z-score value within or above normative value. Some patients had weight for age and BMI for age higher than normal Z-score. Seventy out of 185 patients had some adverse effects with the use of propranolol, but none of them led to drug discontinuation. Both cohorts of patients with or without comorbidities achieved both gross motor and fine motor developmental milestones at or before expected age. Most commonly reported side effect was reflux. Majority of the parents were happy with therapy, 14% were neutral, and 9% were unhappy. Eighty percent had noted improvement in size color or both, mainly within the first month. After stoppage of medication, 12% had reoccurrence of symptoms. Nearly 74% reported second treatment with laser, surgery, or steroids, most of which were to control symptoms such as bleeding or cosmetic adjunct.[1]

This study highlights a high level of acceptance for the therapy among the guardians of children with infantile hemangioma. Only 9% of the guardians were unhappy despite 37.8% having adverse effect and 73.9% patients requiring a second treatment. The level of satisfaction in this study can be misleading and may be different if recorded following second therapy as majority of the patients required a second treatment. The satisfaction level of guardian can be graded on a broader ordinal scale or an interval scale. The current study had only three options of happy, neutral and unhappy for the guardian to choose which may not completely provide the intended outcome. This study underscores the importance of establishing long-term safety profile of propranolol for the treatment of infantile hemangioma.[1] Many studies including systematic review have established safety of propranolol for infantile hemangioma although these studies were focused on the immediate cardiovascular, respiratory, metabolic, and neurological adverse events.[2]

Studies evaluating long-term impact of treatment in children are lacking. There is evidence mainly from adult volunteer studies regarding the effect of propranolol on short- and long-term memory, mood, sleep quality, and psychomotor function.[3] This study examines the developmental milestones of children until 48 months of age, which indirectly evaluates the long-term effects on neurological development, and the data are reassuring for both physicians and parents as the children are shown to have normal developmental milestones.[1]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



Giese RA, Turner M, Cleves M, Gardner JR, Richter GT. Propranolol for Treatment of Infantile Hemangioma: Efficacy and Effect on Pediatric Growth and Development. Int J Pediatr. 2021;2021:6669383. Published 2021 Apr 7. doi: 10.1155/2021/6669383.

Léaute-Labrèze C, Boccara O, Degrugillier-Chopinet C, Mazereeuw-Hautier J, Prey S, Lebbé G, et al. Safety of oral propranolol for the treatment of infantile hemangioma: A systematic review. Pediatrics 2016;138:e20160353.

Langley A, Pope E. Propranolol and central nervous system function: potential implications for paediatric patients with infantile haemangiomas. Br J Dermatol 2015;172:13-23.





 
  References Top

1.
Giese RA, Turner M, Cleves M, Gardner JR, Richter GT. Propranolol for Treatment of Infantile Hemangioma: Efficacy and Effect on Pediatric Growth and Development. Int J Pediatr. 2021;2021:6669383. Published 2021 Apr 7. doi: 10.1155/2021/6669383.  Back to cited text no. 1
    
2.
Léaute-Labrèze C, Boccara O, Degrugillier-Chopinet C, Mazereeuw-Hautier J, Prey S, Lebbé G, et al. Safety of oral propranolol for the treatment of infantile hemangioma: A systematic review. Pediatrics 2016;138:e20160353.  Back to cited text no. 2
    
3.
Langley A, Pope E. Propranolol and central nervous system function: potential implications for paediatric patients with infantile haemangiomas. Br J Dermatol 2015;172:13-23.  Back to cited text no. 3
    




 

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