Different skin diseases, different patients demand specialized treatment

July 2005

Researchers should study and evaluate each dermatological inflammatory condition to provide pediatric patients with proper treatment, said Ronald Hansen, MD, at the 2005 Masters of Pediatrics Conference, held in Bal Harbour, Fla.

Hansen, a professor of dermatology and pediatrics at Phoenix Children’s Hospital in Phoenix, presented his perspective on therapeutic breakthroughs in dermatology.

Physicians should prescribe different treatment regimens for children with different skin diseases, he told a group of attendees, as he took them step-by-step through treatment options for diseases such as vitiligo, psoriasis, lichen sclerosus, pityriasis rosea, Gougerot-Carteaud disease and molluscum.

Vitiligo

Topical immunomodulators, such as tacrolimus (Protopic, Fujisawa) and pimecrolimus (Elidel, Novartis), “really work quite well” for the treatment of vitiligo, Hansen said. While his office has been advising patients about the FDA’s Pediatric Advisory Committee’s recommended “black box” warning, which they suggested because of a possible increased risk of malignancy and other adverse events, Hansen said that they have shown to be as effective as effective as clobetasol. The FDA’s decision on the black box warning was still pending as of press time.

Hansen suggested that tacrolimus “seems to be a little more potent” than pimecrolimus.

One major advantage of tacrolimus and pimecrolimus is that they are topical. Also, there are no concerns about atrophy, striae or systemic absorption. Furthermore, there is no need to monitor intraocular pressure or conduct eye examinations when used on the eyelids.

“Many dermatologists and many pediatricians are not appropriately aware of the potential side effects of using steroids of any level of potency around the eyelids,” he said.

Whether a physician prescribes a hydrocortisone or clobetasol cream, children tend to rub their eyes, which absorbs the ointment and can cause glaucoma. He suggested performing eye pressures on all patients, children or adults, or do not use steroids at all.

“Remember clobetasol is a thousand times more potent in terms of skin assays than hydrocortisone, but glaucoma has nothing to do with the skin potencies,” he said. “Steroids will do that in a small group of individuals, and we don’t know who those individuals are.”

Generally, it can take four to six months before visible changes are seen when using tacrolimus or pimecrolimus, Hansen advised. However in his experience, he said he has seen some “flat out failures on body vitiligo with topical immunomodulators.” In response to such failures, he chooses to use class-1 steroids, such as clobetasol, once a day.

“I watch the patients very carefully when they are on class-1 steroids because they can get thinning of the skin and atrophy,” he said. Regardless, he believes that the new immunomodulators are good.

Psoriasis

Psoriasis is an inflammatory as well as a proliferative condition. Although the new topical immunomodulators appear promising for psoriasis treatment, as promising as mid-potency steroids, they can also be transient and not beneficial for psoriasis.

“I think psoriasis is so hard to treat topically and so frustrating to treat topically that we should welcome any new addition we can use,” Hansen said.

Psoriasis in children more commonly affects the face, he said, while in adults it does not. Again, he stressed the importance of being aware of choosing a treatment that will not have adverse events on the child’s eye. He suggested using tacrolimus or pimecrolimus for psoriasis treatment in children. He does not believe that calcipotriene ointment (Dovonex, Bristol-Myers Squibb) or tazarotene (Tazorac, Allergan) are beneficial treatments for psoriasis in children.

“Dovonex, to me, is expensive, and it has to be used twice a day,” he explained. Tazarotene can be administered once a day. However, he said “it’s so irritating you probably can’t use it more than once a day. Tazorac is not an easy product to tolerate.”

One biological agent for psoriasis is etanercept (Embrel, Wyeth). The FDA approved this treatment last year for use in psoriasis patients 18 years old and older.

“This is actually the only one I have any enthusiasm about, the only one that I’ve had any experience with, and I really think this is a good agent,” he commented. “It was revolutionary for some of the adults and children with psoriatic arthritis, and that’s why it was first approved because it was first and foremost a rheumatoid arthritis drug.”

One beneficial aspect of this drug is that parents can administer it twice weekly, subcutaneously, and it does not require drug monitoring, he said. However, it can be costly. Etanercept costs around $1,000 a month for 25 mg twice a week. Compared with other treatment regimens, however, cost-effectiveness is fair. Pimecrolimus costs about $1.50 per gram, tacrolimus costs about $2 per gram and calcipotriene ointment costs about $1 a gram.

“We really don’t know the long-term safety features of any of the biologicals,” Hansen said. Research has linked use of infliximab (Remicade, Centocor), another drug treatment for psoriasis, with opportunistic infections. Etanercept seems to be the safest of the biologicals, he said, and requires no laboratory monitoring. However, opportunistic infections, such as activation of latent tuberculosis, has been seen.

“The problem with psoriasis is actually pretty simple. The topical treatments work, but don’t work wonderfully. And the systemic treatments really do work, but they’re not completely safe,” he said. “Psoriasis is tough to treat.”

Lichen sclerosus

Hansen said that physicians see lichen schlerosus in two age groups: postmenopausal women and pediatric girls 3 to 7 years old. Generally patients with this disease present with hypopigmentation, atrophy, propria, discomfort and trouble evacuating their stool, he said. It is a major cause of fissures and hardening stool.

Physicians advocate tacrolimus for treatment of lichen sclerosus. Hansen, however, said he has experienced three failures with its use compared to clobetasol; he has not experienced any failures and continues to see a good response from patients treated with clobetasol.

“The concern of course is that you’re treating a tender area, a thin skin area. … There is a long history of class-1 steroids being incredibly effective,” he said. “I know class-1 steroids work. I’m not convinced yet about the topical immunomodulators here, but they should be tested,” he said.

Treatments for other diseases

Hansen also discussed the disease and treatment options for pityriasis rosea. Pityriasis rosea lasts anywhere from three to eight weeks, Hansen said. In treating patients with this disease, he prefers orally administered erythromycin.

“A two-week course will usually clear pityriasis rosea. This really works, not 100% of the time, but more than 50% of the time,” he said.

Gougerot-Carteaud disease, also know as confluent reticulate papillomatosis, is easier to treat than to diagnose, he said. The disease sometimes mimics pityriasis rosea or tinea versicolor.

Many dermatologists mistake it for t. versicolor. However, even if a physician obtains a positive scraping, Hansen said, it will never respond to any t. versicolor treatments. He prefers using minocycline for treatment.

“I probably see four [cases] a year, and I’ve never had a failure in the last, I think, six or seven years using minocycline,” he said. Minocycline is another black box treatment, however.

Fluconazole (Diflucan, Pfizer) is a treatment he recommended for neonatal cephalic pustulosis, an inflammatory condition formerly called neonatal acne. Neonatal cephalic pustulosis is a monomorphous pustule eruption over the face of infants. It usually begins at 3 or 4 weeks old, he said, and usually involves the scalp, as well as the face.

While it can last a couple months, Hansen said it generally goes away on its own. If treatment is warranted, he suggested administering a week of oral fluconazole.

Treatment methods for molluscum are debatable, Hansen said, as he concluded his presentation.

Hansen said that he does not treat most molluscum cases he sees because it too goes away on its own. When Hansen does treat molluscum patients, he prefers cantharone, the “old-fashioned treatment.”

However, he said he has seen one treatment, imiquimod (Aldara, 3M), work well. However, it works slowly and can be unpredictable. A study is underway for imiquimod that aims to assess its efficacy.

For more information:

• Hansen R. New therapeutic breakthroughs: a personal perspective. Presented at the 2005 Masters of Pediatrics Conferences. January 28-31, 2005. Bal Harbour, Fla.
• Dr. Hansen is a paid consultant for Novartis.