Dupilumab, Barrier Care in Pediatric Atopic Dermatitis

By Olivia Hart

A dupilumab poster reported reduced progression to asthma in infants and small children with atopic dermatitis, an effect Mark Lebwohl, MD, called “very impressive” among patients aged 2 to 5.

Lebwohl is dean for clinical therapeutics at the Icahn School of Medicine at Mount Sinai and chairman emeritus of its Department of Dermatology. The dermatologist discussed a poster from Eric Simpson on dupilumab in infants and small children.

The poster summary did not report a trial design, enrollment count, numerical effect estimate or follow-up duration. That limits how far the asthma finding can be read as a quantified, durable prevention benefit.

A poster signal that still needs proof

Lebwohl said treatment reduced the atopic march, with fewer patients going on to develop asthma. He also said the finding needs further proof. If it bears out, it will reinforce the need to treat early rather than wait for severe disease.

He cited bone growth, stature and quality of life as additional reasons for early treatment. Lebwohl described the family burden in practical terms: children with atopic dermatitis and their parents are miserable and lose sleep, he said.

Use biologics before severity escalates

“Our drugs fortunately work quickly, and we need to use them when patients start out with atopic dermatitis. Not wait for them to be severe,” Lebwohl said.

The data have not changed his practice much, he said, but the poster may make it easier to persuade parents that a child needs a biologic. Parents often focus on their child’s height, he said. Telling them that the child will grow taller on a biologic, as opposed to topical therapies or systemic corticosteroids, prompts ready acceptance of biologic treatment.

Barrier care starts with one instruction sheet

Lebwohl gives every patient with atopic dermatitis, pediatric or adult, a written instruction sheet. It covers four practical areas:

• Soap substitutes instead of soap.
• Brief showers or baths with limited heat and duration.
• Prescribed topical therapy or moisturizer applied immediately afterward.
• Laundry materials, humidifiers in winter and air conditioning in summer.

Some moisturizers contain therapeutic agents such as ceramides, which Lebwohl believes help the skin barrier. His counseling therefore combines replacement of standard soap with immediate treatment or moisturization and attention to the household environment.

Diet referral for infants

Most dermatologists care for pediatric patients, and some work alongside pediatric allergists, Lebwohl said. At Mount Sinai, infants are often referred to a pediatric allergy group to determine whether diet contributes to their disease.

“The vast majority of cases, diet does not play a role, but there are in pediatrics in particular a small but real number of patients in whom diet does play a role,” Lebwohl said.

When diet contributes, patients are taught to avoid the foods exacerbating their condition. The referral is therefore aimed at identifying food-related disease rather than placing every infant on an elimination diet.

Bleach baths for impetiginized skin

When skin becomes impetiginized, Lebwohl may prescribe bleach baths to reduce bacterial burden. He noted that many patients with atopic dermatitis are colonized by Staphylococcus aureus. For those patients, he said, bleach baths may be prescribed.

What does this change for families considering early treatment?

For now, the practical change is earlier discussion of biologic therapy when pediatric atopic dermatitis begins, not a promise that dupilumab prevents asthma. Lebwohl’s case for early use rests on rapid drug effects and his concerns about bone growth, stature and quality of life; the asthma reduction still needs confirmation before it can carry more weight.

Barrier care remains the baseline for every patient, with diet referral used to assess food contributions in infants and bleach baths considered for impetiginized skin with Staphylococcus aureus colonization.

If the reduction in asthma among children aged 2 to 5 is confirmed, it would give clinicians a stronger reason to treat early rather than wait for severe disease.