Biologics in Early Childhood and Adolescence
Daphne Bakker (The Netherlands)
Atopic dermatitis (AD) is one of the most common chronic inflammatory skin diseases, affecting up to 20% of the pediatric population. Although topical corticosteroids are the first-line treatment, they often prove ineffective in curbing moderate-to-severe AD, where systemic treatments are required. An improved understanding of AD pathogenesis has recently led to the development of the first targeted therapies: Dupilumab, an interleukin (IL)-4 receptor-α monoclonal antibody inhibiting IL-4 and IL-13 signalling, is approved for the treatment of moderate-to-severe AD patients as young as 6 months in Europe and the United States. Tralokinumab, a biologic directly inhibiting IL-13 cytokine, is currently approved for use in patients aged 12 years or older in Europe. Lebrikizumab, which neutralizes IL-13, has completed adolescent trials and will soon be submitted for approval.
Biologic treatment significantly improved disease severity and disease-associated symptoms in pediatric patients with moderate-to-severe AD in clinical trials as well as in daily practice, and the safety profile is superior to that of immunosuppressant alternatives. Ocular surface disease is clinically the most significant side effect in all three biologics, and additional adverse events have been described since the commercial availability of dupilumab (including alopecia areata and psoriasiform eruptions). The availability of these first biologics for pediatric AD has shifted the treatment paradigm from requiring broad immunosuppressants to more targeted and safer alternatives. However, these introductions come along with new challenges.
In recent years, understanding of the role of C. acnes has expanded. It is still acknowledged to have an important place in acne pathogenesis, but evidence suggests that an imbalance of individual C. acnes phylotypes with a predominance of the phylotype 1AI acts as an acne trigger. In addition, it is now believed that Staphylococcus epidermidis is also a factor in acne development. Together, C. acnes and S. epidermidis maintain and regulate the homeostasis of the skin microbiota. Antibiotics, which have long been a staple of acne therapy, induce cutaneous dysbiosis. In addition, very recently interactions between the gut microbiome and the sebaceous gland have been identified, which could be one of the ways by which diet and mainly sugar could play a role in acne. These findings, together with the long-standing public health edict to spare antibiotic use, when possible, highlight the need for a change in acne management strategies, opening the door to probiotics (substances that influence the growth of microbiome) and prebiotics (products secreted by the microbiome).
Allergic Contact Dermatitis in Children
Anna Belloni Fortina (Italy)
Allergic contact dermatitis is a prevalent skin condition, affecting up to 20% of the population. While allergic contact dermatitis is well-documented in adults, evidence concerning its impact on children is often scarce and discordant.
However, contact sensitization is frequent in the pediatric population, especially in very young children and patch testing is the criterion standard for the diagnosis of allergic contact dermatitis. Furthermore, there are some emerging contact allergens present in antiseptics, “slime” toys, glucose monitors and electronic equipment, among others, that should be investigated in the pediatric population.
Despite conflicting findings in the literature, there is an ongoing need to explore the relationship between disease processes to provide optimal care for pediatric patients affected by these conditions, bearing in mind that children have unique needs and challenges.
When there is a suspicion of contact allergy, or when dermatitis does not respond to conventional therapies, it is crucial to conduct a patch test, even in pediatric patients to avoid a delayed diagnosis and the exacerbation of symptoms.