The Importance of Timing With Live Vaccinations in Pediatric Atopic Dermatitis

Colleen Cotton, MD, is a board-certified dermatologist and pediatrician at Children's National Hospital and assistant professor of dermatology and pediatrics at George Washington School of Medicine in Washington, DC. She spoke with Dermatology Times® to share pearls about pediatric atopic dermatitis, how it's important to time biologic injections with live vaccinations, and how to have conversations about different treatment options with families. She presented 2 sessions at Maui Derm NP+PA Fall 2023 in Asheville, North Carolina from September 27-30.

Dermatology Times: What questions do you ask families to ensure a child gets the most out of a topical treatment?

Cotton: When we have kids come to see us for atopic dermatitis, a lot of times, we are able to manage those kids with topical medications, even if they look really bad to start. It's kind of impressive what an appropriate amount of an appropriate strength topical steroid can do in those cases. A lot of times when I'm seeing a family for the first time, I'm trying to get a sense of how much of the medication have they been given. If they're saying that triamcinolone doesn't work for them, but they've been given a 15 gram tube for 1 month for their entire body, well no wonder it's not working for them. They don't have enough. And also to find out how often they're using it. Sometimes the fear of God has been placed in them and in using these topical steroids, the fear of topical steroid withdrawal is very real. I have patients who are like why don't use it for more than 2 or 3 days just to kind of calm it down, but they're never treating to get clear. So a lot of it is trying to get a sense of how people are using these medicines. So that we might be able to shift that into a way where we emphasize treating to target, treating to clear, because much easier to maintain patients when you can actually get that inflammation and that skin fully healed up.

Another thing that's really important in pediatric patients, that may not be something that adult providers think about as much is the the type of vehicle for what you're using. If it's a flare medication, you don't want to give a kid a cream because they have scratched themselves open, and you put a cream on that, it burns. It's really uncomfortable. And so it's not going to work because mom isn't going to want to use it because it's hurting their child when they're applying it.

Dermatology Times: What is an alternative to a topical cream?

Cotton: Instead, you want to use ointments in children. We don't use them in adults very much because people don't like to be greasy, but a little kid doesn't care about being greasy. They care about something going on their skin that hurts and you really can't explain to them why it's important for them to put something on that burns. So ointments are really, unless I have a very strong reason where the kid is old enough and asking me for a cream, then I will always be using ointments in my younger kids. And it's important to keep in mind that there is a vast difference in strength between some creams and ointments. So just be aware of that.

If there's something that you typically use for the face, for example, as a cream and an adult may not be appropriate to use that same medication as an ointment for the face on a child. And then kids do need biologics sometimes. And so how do you have that conversation, especially with dupilumab being the only biologic approved for kids. Luckily, we have it down to 6 months of age. But it is an injection. And so that can be hard to sell parents on and hard to teach them how to do. So first off, you want to make sure you have the dosing correct because the dosing varies depending on the patient's age and their weight, whether or not they need a loading dose or not, whether it's every 2 weeks, or every 4 weeks, the dose within those dosing periods.

So it's important. I prescribee this all the time, and I still reference the the literature saying like this is what you're supposed to do, just to make sure that we have it correct. And then keeping up as those kids get older, if they gain weight, and they're dupilumab stops working, then they may need to go to the next step up. So something to consider there. It's also currently not recommended to give live vaccinations with dupilumab. And there is some anecdotal evidence of a few patients who accidentally received live vaccinations. It looks like it's still safe, but the jury's out and we can't officially recommend that. So it's something that's important to keep in mind. I mean, if you have a kid who's 2-years old, and they need dupilumab, put them on dupilumab. But if you have a kid who's maybe 4 or 5, they're eligible for their 6 year/kindergarten vaccines, which contain to live vaccines: their second doses of varicella and MMR.

So it may be a good idea to make sure they get those before you start the dupilumab because it's a really difficult conversation when someone is doing well to say, "Hey, I want to take you off this great medication for several months so that you can get this vaccination," for something the parent may not think is that significant of a risk.

Dermatology Times: When prescribing biologics, what are the pros and cons of a pre-filled syringe versus a pen?

Cotton: It's really a patient comfort and patient preference type of thing. I present it to you every kid who is old enough to kind of have an opinion about whether they want a prefilled syringe or a pen. I was kind of surprised when the pen came out. I was initially really excited because I'm like, "Yes, we have an option for our needle phobic patients. It's going to be so much better. They don't have to see the needle." But what I got when I started to switch a lot of patients to it was patients coming back to me and saying, "I want to go back to the prefilled syringe, because the pen is more painful when it goes in." Now, if I have a teenager who absolutely cannot look at the needle, and they're like, "I don't care how much it hurts, as long as I don't have to look at that needle," then they're the perfect patient to have the pen. If I have a patient who really cares more about the pain and discomfort of that medicine going in, because dupilumab is quite viscous as a liquid. And so as it goes in, it's one of the more painful injectable medications that we have, which is not necessarily similar to some of the other biologics, especially with psoriasis that people might be more familiar with. So using the syringe, you can inject more slowly and actually control the pace at which it goes in.

The other thing about the pen that many people don't read the instructions correctly, is that once you push it in, you get one click, you have to wait several seconds, then there's a second click, you have to wait 3 or 5 more seconds after that before you can take the pen out. People often take the pen out right after that second click and then the medication is leaking out. They may not have gotten their absolute full and complete dose, which could affect the effectiveness of the medication. So it's a conversation that I have with everybody. Most of them do choose to use the prefilled syringe, but it is really nice to have the pen available for people who can't manage that.

Dermatology Times: Why should a clinician consider vaccination timing in younger children in atopic dermatitis treatment?

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Cotton: It depends on the age of the kid for sure. The big live vaccine moments in kids one is like right after birth with rotavirus, so we don't usually have to worry about that. They don't usually have atopic dermatitis yet. And then the next time is at 1 year of age. Now, we rarely have to use dupilumab under the age of 1, but it was really nice to have in our toolbox if it's necessary. And so those kids usually do have either some other immune deficiency or an immune dysregulation. So there may already be a consideration about their vaccinations at that point. So that's usually a conversation I'm having with immunology about whether or not we should be giving that before we start the medication or not. After that, the next time for live vaccines is between 4 to 6 years of age. And most people wait to give those until kids are going into kindergarten, so usually a little bit later in that timeframe. But you can get them as early as 4 years old. So if you have a patient who's in that age group and you're thinking about starting dupilumab, but they have not yet gotten those vaccines, I think it's a better idea to talk with them, to have them see their pediatrician and get those vaccines early, still within the 4 to 6 year time range. Rather than putting them on the medication, having them do well and then having to have a difficult conversation, whereas the current recommendation now is to stop dupilumab for 1 to 2 months, then give the vaccine, then wait another 4 weeks before restarting, which can, for kids who have been in and out of the hospital with severe infections related to their atopic dermatitis, that's a hard sell for a lot of parents. And I have some parents where we have had the conversation and they've spoken with their pediatrician. And they've made the choice not to give that second set of live vaccinations, at least until the child's a little bit older and may be able to handle a break from their dupilumab for a little bit longer. So if there is any way we can get those vaccines into kids before they start the medication, it's a much better situation all around.

Dermatology Times: What else is important to know with several atopic dermatitis treatment options available?

Cotton: It is also important to keep in mind what's available to you in your toolbox based on ages of approval. So, in terms of nonsteroidal topical medications, we do have crisaborole, which is approved down to 3 months of age, which is pretty great, but can burn in a good proportion of kids. So I usually use it as a maintenance medication, really when they're either not having flares, or they're very mild to help prevent flares. I tell parents to still use it on a test spot first. It is definitely not something you want to be trying in a kid with a flare where the parents like, "I just want something that's not a steroid." This is not your medication for that if they're severely flared up. And that is approved from 3 months onward, which is great are other nonsteroidal topicals tacrolimus and pimecrolimus have been around for a long time. They're only approved down to the age of 2. So that may be more difficult to get for a child under that age and the 0.1% of tacrolimus is only approved for 16 and up. You may find yourself having some trouble getting coverage for those specific medications at younger ages and it's something to keep in mind. Similarly, topical ruxolitinib is only approved down to age 12, and that is really difficult to get under that age. So something else that we have in our toolbox but really only for patients at certain ages right now.

Transcript edited for clarity