Lisa Swanson, MD, PhD: Clinical Pearls in Pediatric Dermatology

At the 2023 Society of Dermatology Physician Assistants (SDPA) Annual Fall Dermatology Conference in Nashville, TN, held October 26-29, 2023, Elizabeth (Lisa) Swanson, MD, PhD, from Ada West Dermatology and St Luke’s Children’s in Idaho, presented sessions centered around pearls in pediatric dermatology.

Swanson sat down with Dermatology Times at the conference to discuss key highlights and takeaways from her sessions, "Infantile Hemangiomas," and "Challenging Cases in Pediatric Dermatology."

Transcript

Lisa Swanson, MD, PhD: Hi, I'm Lisa Swanson. I'm a dermatologist and pediatric dermatologist. I'm in private practice in Boise, Idaho, at Ada West Dermatology, and I also go to St. Luke's Children's Hospitals. I do some consults and perform procedures there.

Dermatology Times: What are highlights and takeaways from your session, "Infantile Hemangiomas?"

Swanson: So we talked about a lot when it comes to infantile hemangiomas. We talked about how important it is to treat hemangiomas that need treatment: so big ones, ulcerating ones, ones that are in functional locations, ones that are in what we call special sites, like the eyelid, nose, and lip. I really tried to get the audience to feel comfortable with treating hemangiomas because there are only around 335 pediatric dermatologists in the whole country, and so we cannot treat all the hemangiomas that need treating. We need help. I wanted to inspire and empower the audience members to feel comfortable. We mostly use an oral medication called propranolol to treat hemangiomas, and it's very effective, and it's very safe.

I shared some stories of treatment, success stories, and important tidbits about counseling parents about the medication. In the early days of using propranolol, a lot of centers were doing echocardiograms before starting the medicine, or they were even admitting kids to the hospital for the initiation of therapy. We know now that we don't have to do that, and if you're treating an otherwise healthy baby with no other comorbidities or conditions, that you can just simply start the propranolol. It's very well-tolerated. It's very effective, and it's a medicine I hope all attendees left feeling comfortable with.

We talked about topical timolol and when might you consider topical timolol to treat a hemangioma, and I shared with the audience that there are 3 major types of hemangiomas. There's superficial, where it's just like a strawberry on the skin. There's deep, where it's a blue bump under the skin, and then there's combined, where it's a blue bump with a strawberry on top. Topical timolol will only work for the superficial types of hemangiomas. So we talked about that. I mentioned that it's very important to not use topical timolol on an ulcerating hemangioma because it can lead to some unpredictable systemic absorption.

We also talked about hemangiomas in certain locations that can tell you that there might be some something else going on. The little baby might have another condition. There are hemangiomas that occur on the face in a segmental patter. They can be associated with a condition called PHACES. Each of the letter stands for part of the condition. And then hemangiomas in the diaper area in the perineal area, the perianal area, those can also be associated with another condition called PELVIS syndrome. We talked about the features of those conditions, what you need to screen for, what tests you need to do, and we talked about that in detail, which hopefully helped everybody.

Dermatology Times: What are highlights and takeaways from your session, "Challenging Cases in Pediatric Dermatology?"

Swanson: We talked about a lot. My first case was talking about a young patient with psoriasis. A lot of people don't realize that kids get psoriasis, and the incidence of psoriasis in kids has really increased over the years. I've been in practice 13 and a half years. When I first started, I would see one new pediatric patient with psoriasis every month, and nowadays, it's one every day. It's been that way for the past 5 to 6 year, so the incidence is really increasing over time. I think also, sometimes there can be a tendency to undertreat kids with psoriasis, simply because the provider might not have that comfort level with treating kids, but I really tried to empower the folks in the audience to feel comfortable treating psoriasis. It's important to treat psoriasis, both for our patients' quality of life, and also to hopefully help mitigate potential comorbidities that we could see over time. Psoriasis is a systemic disease with systemic implications. It makes sense to treat it systemically. I really tried to share some stories and some tidbits that hopefully allowed people to go out there next week and say, "I'm going to treat some kids with psoriasis this week."

Then I talked about a case of a little child, little girl, with chronic bullous disease of childhood, that had a rare side effect to a medicine called dapsone. She suffered methemoglobinemia as a result of her dapsone therapy. And so of course, we had to stop the dapsone. And then we were left with a therapeutic dilemma. If we can't use dapsone, what are we going to use? And we also had to deal with the PTSD that myself and her mom experienced as a result of the methemoglobinemia, which was really traumatic on all of us. She had to be admitted to the PICU and receive proper therapy. Very stressful situation. So what medicine would we feel comfortable with, after going through all that? I shared how I had sent an email out to my peds derm phone a friend circle, and one of the ideas from one of my friends was to start dupilumab, which theoretically might not work because chronic bullous disease of childhood, which is a neutrophilic disorder and dupilumab works best for eosinophilic disorders. But dupilumab is very safe and doesn't require any lab monitoring, and so we made the decision, me and her mom, and her, to go ahead and start her on that treatment. She's done wonderfully. So I showed some before and after pictures.

We also talked about a patient with vitiligo on the face that was a successful treatment story with topical ruxolitinib. I talked about how I like to combine topical ruxolitinib for vitiligo with an oral supplement called Heliocare, polypodium leucotomos. We know that Heliocare makes light therapy work better in the treatment of vitiligo, and we know that topical ruxolitinib works better with light therapy. So if we build on those strengths of efficacy, hopefully we get better results, and so I frequently use that combination.

Then, we talked about a pediatric patient with atopic dermatitis that I started on dupilumab, which was really a life-changing treatment for him. I talked about some commonly-asked questions using the dupilumab in the younger patients, including, "How long will my child need to be on this medicine? How are we going to administer the medicine because it is a shot and kids don't like shots? And what do we do about live vaccinations in these younger patients per label live vaccines are to be avoided on dupilumab?" The 2 most common live vaccines are the MMR and chickenpox vaccinations, and those are given between the ages of 1 and 2 and again between the ages of 4 and 5, and so I shared that most pediatric dermatologists, what we'll do is we'll give the Dupixent. We'll wait a month, have them get their vaccinations, wait a month, restart Dupixent, and so that's how most pediatric dermatologists are managing the live vaccine questions with the drug. I talked about some tips on how I administer the injection to the kiddos that I treat, ways to make it better. I really focus a lot on emphasizing to both the patient and their caregiver just how much this medicine is going to help them and how they're going to feel better so much more of the time than they do right now. That yeah, it's a shot and shots hurt. But that 3 seconds of discomfort once or twice a month to feel better all the other seconds of all the other days, is a trade off that I think is incredibly worthwhile, and so I don't sugarcoat the ouch factor. I just say, "Yeah, there's a little ouch. But if it works, it works. You'll feel better."

And then we talked about an older patient, a teenage patient with bad atopic dermatitis that had initially improved with dupilumab, but then suffered a setback, and I switched her to an oral JAK inhibitor, and so we talked about the oral JAK inhibitors, upadacitinib and abrocitinib, that they're both approved age 12 and up. We talked about their rapid efficacy, especially when it comes to itch. We talked about the impact these drugs can have on patients' lives and their quality of life, and of course, we talked about safety, because what's a talk about a JAK inhibitor without talking about safety? We talked about safety in detail, how I have that conversation with my patients and their families, how I break down the boxed warning for folks, hopefully to help people to feel comfortable having that conversation with their patients. Because honestly, these medicines are fantastic. They offer opportunities for our patients that we haven't been able to offer before, and to just ignore them because there's this box warning is a disservice to everybody. These medicines would be flying off the shelves like Ozempic if it weren't for the box warning. So we need to learn about the warning, feel comfortable with the warning, come up with ways that we can discuss the warning with our patients that make us confident during that interaction that we're doing the best job. We're being mindful of safety, but we're also encouraging our patients to experience the wellness that these medicines can provide, because it's really pretty fabulous.

Dermatology Times: What is new or upcoming in dermatology and pediatric derm that excites you?

Swanson: So much. Really, to be practicing medicine, to be practicing dermatology, to be practicing pediatric dermatology, at this time in history, it's wonderful. We've had so many good things happen for us in recent years and the gifts are just keeping on coming in the future. We're looking forward to the approval of 3 topical non steroids for young patients with atopic dermatitis.

One of them is called tapinarof (VTAMA). It's currently approved for psoriasis aged 18 and up, but they did studies for atopic dermatitis down to the age of 2 in moderate to severe atopic kids with really stellar results with no limitation on body surface area that you can treat it with. It's a once-daily topical nonsteroidal cream. So we're looking forward to the approval of that drug for atopic dermatitis down to age 2.

We're looking forward to the approval of roflumilast (ZORYVE) in the atopic dermatitis world. It's currently approved to treat psoriasis for patients aged 6 and up, but they've done their atopic dermatitis studies. We're looking forward to an approval in that realm. It's also a once-daily topical nonsteroidal cream, and so we're very much looking forward to having more choices in that realm.

And then topical ruxolitinib is currently approved to treat patients 12 and up with atopic dermatitis. But they've done studies down to the age of 2, and we're very much looking forward to an expanded label change so that we can treat our younger patients with topical ruxolitinib.

One other thing that I'm very much looking forward to: there's a medication called lebrikizumab that was due for FDA approval at the end of September, but it's been delayed at the FDA. And so I can't wait to get this medicine in my toolbox. It's an IL-13 inhibitor, it's a biologic, its efficacy and safety appears excellent, quite on par with dupilumab which we've known for 6 and a half years now and have a tremendous amount of experience with. The one advantage to lebrikizumab is that it appears there's increased flexibility and spacing out the shots, which of course is meaningful to any patient to have fewer shots, and so we can't wait for that to gain approval at the FDA. We're sad it got delayed, but we're looking forward to when it's finally available.

[Transcript has been edited for clarity.]

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