PracticeUpdate: Dermatology & Rheumatology

AMERICAN ACADEMY OF DERMATOLOGY 2016 SUMMER ACADEMY MEETING 18

Dr Sheila Friedlander discusses advanced systemic therapeutics for paediatrics

Summer AAD 2016 28–31 JULY 2016 • BOSTON, MASSACHUSETTS, USA Having attended the Summer AAD 2016, Drs Sheila Friedlander, Mark Kaufmann and Misha Rosenbach share

Sheila Friedlander MD is Director of the Dermatology Fellowship Training Program at Rady Children’s Hospital-San Diego and Professor of Pediatrics and Dermatology at UC San Diego, California.

their perspective on advanced systemic therapeutics.

SYM S001 – advanced systemic therapeutics Atopic dermatitis

form. The regular tablet can be split in four if necessary for proper paediatric dosing. Many experts initiate low-dose therapy (eg, 0.25 mg at bedtime), but most children tolerate dosing in the 2- to 6-mg range. A recent randomised clinical trial with crossover conducted by Chang et al enrolled 73 patients with AD and sleep disturbance ( JAMA Pediatr 2016;170:35-42). A significant improvement in sleep latency (P = 0.005) and SCORAD scores was achieved by 9 patients treated with 3 mg melatonin at bedtime. In children with severe AD, dupilumab may be an option. This injectable monoclonal antibody to the IL-4 receptor has shown excellent efficacy in adults, and paediatric trials are ongoing. Thaci and colleagues recently published the results of a randomised placebo-controlled trial assessing several dosing regimens in adults ( Lancet 2016;387:40-52). The most optimal effect was seen with 300 mg dupilumab once a week. There was a small increase in perioral herpes infections, but the safety profile was reassuring.

Atopic dermatitis (AD) poses a tremendous therapeutic challenge in paediatric dermatology, and systemic therapy is sometimes required. There are several options, and one is the “old” drug melatonin. The hormone melatonin is produced by the pineal gland and is crucial for normal sleep cycling and circadian rhythm. It also has immunomodulatory and antioxidant effects. Patients with AD have disrupted sleep cycles, affecting both sleep latency and duration, and exogenous melatonin is generally a safe drug when used in doses of 0.5 to 10 mg at bedtime and is a reasonable option for children with AD whose sleep disturbance has not responded to traditional therapies. Reported side effects include morning drowsiness, bedwetting, headache, and nausea. Melatonin comes in a liquid formulation, tablet, sublingual dissolving tablet, and time-released

Dr Mark Kaufmann discusses systemic therapeutics Mark Kaufmann MD is Associate Clinical Professor of Dermatology, Icahn School of Medicine at Mount Sinai, New York, New York. SYM S001 – advanced systemic therapeutics At the Summer Academy symposium on systemic therapeutics, I spoke about the “forgotten” systemic drugs. These include methotrexate, cyclosporin, and dapsone – drugs that we all trained in how to use, but, with newer larger molecules (like biologics), we tend to forget about. I reviewed appropriate patient selection, how to dose the drugs, and how to best monitor our patients while on these medications.

I also (re-)introduced subcutaneous methotrexate. The rheumatologic literature points to the subcutaneous form as having more predictable bioavailability, superior efficacy, and better GI tolerability. In addition, there was a recent article in the Journal of Drugs in Dermatology (2016;15:345- 349) which suggested that subcutaneous methotrexate should be considered in the first line (rather than the oral form), and that, by doing so, there would potentially be more patients achieving a positive response to methotrexate. This, in turn, would lead to fewer patients requiring treatment with biologics, thereby lowering the total cost to the healthcare system. The authors suggested a randomised controlled head-to-head study of oral versus subcutaneous methotrexate to help further clarify this issue.

PRACTICEUPDATE RHEUMATOLOGY & DERMATOLOGY