Don’t Be Rash: The Pediatric Dermatology Podcast

00:00:02.340 –> 00:00:05.080
Welcome to the Don’t Be Rash Pediatric Dermatology

00:00:05.080 –> 00:00:07.679
Podcast, the owner’s manual for your kid’s skin.

00:00:07.839 –> 00:00:10.820
I’m your host, Dr. K, board-certified pediatric

00:00:10.820 –> 00:00:13.640
dermatologist and father of two boys. I’m here

00:00:13.640 –> 00:00:15.880
to chat with you to promote dermatological education

00:00:15.880 –> 00:00:18.859
and improve skin health in our children everywhere.

00:00:19.500 –> 00:00:29.140
Let’s get started. Welcome to Don’t Be Rash,

00:00:29.359 –> 00:00:31.539
the pediatric dermatology show, coming to you

00:00:31.539 –> 00:00:34.119
from historic Bethlehem, Pennsylvania. I’m your

00:00:34.119 –> 00:00:36.179
host and board-certified pediatric dermatologist,

00:00:36.340 –> 00:00:39.119
Dr. Andrew Krakowski. On today’s show, we’re

00:00:39.119 –> 00:00:41.259
going to continue our deep dive into the world

00:00:41.259 –> 00:00:43.640
of eczema and focus on what it means to have

00:00:43.640 –> 00:00:47.100
severe atopic dermatitis. More specifically,

00:00:47.159 –> 00:00:49.359
in the first half of the show, we will discuss

00:00:49.359 –> 00:00:52.240
what constitutes a diagnosis of severe atopic

00:00:52.240 –> 00:00:54.560
dermatitis and discuss some of the potential

00:00:54.560 –> 00:00:57.329
reasons why a child might end up at that level

00:00:57.329 –> 00:01:00.789
of severity in the first place. Then in the second

00:01:00.789 –> 00:01:02.710
half of the show, we will discuss management

00:01:02.710 –> 00:01:05.189
approaches, including a discussion around systemic

00:01:05.189 –> 00:01:09.150
therapies. Joining us today as our guest co-host

00:01:09.150 –> 00:01:11.310
is world-renowned pediatric dermatologist, Dr.

00:01:11.510 –> 00:01:14.349
Robert Sidbury. Dr. Sidbury is chief of pediatric

00:01:14.349 –> 00:01:16.709
dermatology at Seattle Children’s Hospital in

00:01:16.709 –> 00:01:19.469
Washington State. He’s really been a guiding

00:01:19.469 –> 00:01:21.109
voice in terms of the approach to management

00:01:21.109 –> 00:01:23.790
for patients with severe atopic dermatitis and

00:01:23.790 –> 00:01:26.129
has been a leader on numerous expert panels and

00:01:26.129 –> 00:01:29.209
consensus guidelines on the subject. Welcome,

00:01:29.329 –> 00:01:31.430
Dr. Sidbury. Thanks for joining me today. Thank

00:01:31.430 –> 00:01:33.310
you very much for having me, Dr. Krakowski. It’s

00:01:33.310 –> 00:01:35.569
a pleasure. So what comes to your mind clinically

00:01:35.569 –> 00:01:38.069
when someone asks you about a child suffering

00:01:38.069 –> 00:01:40.689
from severe atopic dermatitis? How’s that different

00:01:40.689 –> 00:01:44.090
from, say, mild or moderate in your mind? Well,

00:01:44.129 –> 00:01:46.909
really just the misery of it, to be honest. It

00:01:46.909 –> 00:01:51.390
is just such an all-encompassing thing with

00:01:51.390 –> 00:01:56.569
sort of incessant itch, chronic sort of scratched

00:01:56.569 –> 00:02:01.420
open skin, risk of infection. and all compounded

00:02:01.420 –> 00:02:05.159
by the sort of injustice of oftentimes those

00:02:05.159 –> 00:02:07.959
who see it, because as you know, eczema is a

00:02:07.959 –> 00:02:11.539
very visible disorder, referring to it as “just

00:02:11.539 –> 00:02:14.219
eczema” – my least favorite two words to put together

00:02:14.219 –> 00:02:17.639
in the dictionary – because it may well capture

00:02:17.639 –> 00:02:20.819
very, very mild eczema that gets better with

00:02:20.819 –> 00:02:24.300
a little petrolatum, but it very much does not

00:02:24.300 –> 00:02:27.280
capture this extent of disease. And I always

00:02:27.280 –> 00:02:30.659
will tell pediatric residents even who rotate

00:02:30.659 –> 00:02:33.699
with us and have that sort of misimpression of

00:02:33.699 –> 00:02:36.159
the impact that this disease can have. It’s like

00:02:36.159 –> 00:02:40.039
if you’ve had some contact dermatitis, a poison

00:02:40.039 –> 00:02:43.599
ivy, or a bug bite, and you’re itching from it,

00:02:43.699 –> 00:02:46.939
it can drive you batty. And that’s a one – or

00:02:46.939 –> 00:02:50.379
two-day proposition. This is a 24/7, 365 deal.

00:02:51.340 –> 00:02:53.259
It is essentially that. Andrew was just sort

00:02:53.259 –> 00:02:55.280
of trying to paint that picture of what severe

00:02:55.280 –> 00:02:57.639
eczema is and how all-encompassing it is and

00:02:57.639 –> 00:03:01.139
the lifestyle changes kids have to make to accommodate

00:03:01.139 –> 00:03:04.460
it. The clothes they can’t wear, the play dates

00:03:04.460 –> 00:03:07.460
they can’t have, the medicines they have to take,

00:03:07.479 –> 00:03:10.460
both topically and systemically. All of that

00:03:10.460 –> 00:03:14.300
sort of gets to this extent. And of course, as

00:03:14.300 –> 00:03:17.360
you know, there are studies require metrics,

00:03:17.699 –> 00:03:20.340
investigator global assessment scores, amount

00:03:20.340 –> 00:03:23.060
of body surface area, depending on what you look

00:03:23.060 –> 00:03:25.360
at, either more than 10 % or 15 % of the body

00:03:25.360 –> 00:03:27.639
surface area. So there are all these ways that

00:03:27.639 –> 00:03:31.039
we capture what is severe eczema, but it’s really

00:03:31.039 –> 00:03:33.620
that big picture of just how impactful it is.

00:03:34.930 –> 00:03:37.370
Certainly, when you talk about body surface area

00:03:37.370 –> 00:03:40.389
and sort of the, you know, is it totally clear,

00:03:40.490 –> 00:03:43.069
mild, moderate, or severe, that misses the entire

00:03:43.069 –> 00:03:46.270
picture of the psychological aspect of the condition

00:03:46.270 –> 00:03:48.889
as well. And I think you alluded to it, but tell

00:03:48.889 –> 00:03:51.150
us a little bit about what severe patients might

00:03:51.150 –> 00:03:54.409
be experiencing from a psychological or psychosocial

00:03:54.409 –> 00:03:57.939
perspective. Oh, it’s tremendous. I mean, one

00:03:57.939 –> 00:04:00.900
of the more fundamental things is the amount

00:04:00.900 –> 00:04:04.539
of sleep loss that there is. And, you know, any

00:04:04.539 –> 00:04:07.740
of us who have a bad night’s sleep don’t need

00:04:07.740 –> 00:04:09.979
to be told the psychological impacts the next

00:04:09.979 –> 00:04:12.439
day because our co-workers are probably telling

00:04:12.439 –> 00:04:16.319
us. It is just incredibly impactful. And for

00:04:16.319 –> 00:04:19.500
kids – I’m a pediatric dermatologist, so I will

00:04:19.500 –> 00:04:22.439
speak specifically of the pediatric population,

00:04:22.540 –> 00:04:25.779
but this is true for adults with poor performance

00:04:25.779 –> 00:04:28.360
or impaired performance at work – but for kids,

00:04:28.399 –> 00:04:32.939
their concentration is affected, their ability

00:04:32.939 –> 00:04:35.980
to focus at school. Oftentimes, there’s a question

00:04:35.980 –> 00:04:38.779
of whether or not one of the comorbidities associated

00:04:38.779 –> 00:04:41.740
with atopic dermatitis is attention deficit hyperactivity

00:04:41.740 –> 00:04:44.660
disorder. That can be challenging, right? Because

00:04:44.660 –> 00:04:47.160
they’re losing so much sleep, they’re tired and

00:04:47.160 –> 00:04:49.339
they’re inattentive. And so that can be sort

00:04:49.339 –> 00:04:52.800
of a challenging thing to untangle. And I think

00:04:52.800 –> 00:04:54.930
what’s Really interesting as you probe deeper

00:04:54.930 –> 00:04:58.449
into this. It’s not just the child or the adult

00:04:58.449 –> 00:05:02.029
patient It’s the child affected by eczema and

00:05:02.029 –> 00:05:04.810
then the parents who are also not getting a good

00:05:04.810 –> 00:05:07.610
night’s sleep either because the child’s in the

00:05:07.610 –> 00:05:10.480
other room keeping them up knocking on the door,

00:05:10.540 –> 00:05:12.980
asking for help, asking for something to relieve

00:05:12.980 –> 00:05:15.939
that itch, or we know the adults will sometimes

00:05:15.939 –> 00:05:18.819
bring the child patient into the bed with them.

00:05:18.959 –> 00:05:21.180
Now you have three people potentially, or more

00:05:21.180 –> 00:05:24.860
than that, kicking, disturbing their sleep. Now

00:05:24.860 –> 00:05:27.439
their work performance is suffering. That can

00:05:27.439 –> 00:05:29.860
affect their employment. That can affect a promotion

00:05:29.860 –> 00:05:32.839
that was competitive until, geez, “The last couple

00:05:32.839 –> 00:05:35.360
of weeks, you look like you haven’t slept, John.

00:05:35.540 –> 00:05:37.399
I think we’re going to go with Mary on this one!”.

00:05:38.920 –> 00:05:42.019
I think it kind of snowballs from that perspective.

00:05:42.300 –> 00:05:45.800
Marital relations have been affected by other

00:05:45.800 –> 00:05:48.319
children’s suffering from this condition. So

00:05:48.319 –> 00:05:50.480
to me, it’s always interesting, not just the

00:05:50.480 –> 00:05:52.939
patient, other kids too, even unaffected kids

00:05:52.939 –> 00:05:55.220
within a family. They can’t do some of the things

00:05:55.220 –> 00:05:58.029
that they want to do. And it gets lost. That’s

00:05:58.029 –> 00:05:59.970
not captured as far as I’m concerned when you’re

00:05:59.970 –> 00:06:02.649
trying to make the case for a particular medication

00:06:02.649 –> 00:06:05.389
to the insurance company or the prior authorization

00:06:05.389 –> 00:06:08.930
team. You can’t really objectively quantify that

00:06:08.930 –> 00:06:12.910
easily. And it’s unfortunate. Makes our job harder.

00:06:13.709 –> 00:06:17.189
100%. Atopic dermatitis eczema is a family disorder.

00:06:17.660 –> 00:06:20.500
It is not just the individual who suffers from

00:06:20.500 –> 00:06:22.939
it. Oftentimes, because it tends to run in families,

00:06:22.959 –> 00:06:25.920
it can be literally more than one patient who

00:06:25.920 –> 00:06:28.000
was affected by it. But even if there’s only

00:06:28.000 –> 00:06:30.360
one, for all the reasons you say, if you want

00:06:30.360 –> 00:06:33.339
to look at the data, a kid with moderate to severe

00:06:33.339 –> 00:06:36.860
eczema loses 2 .1 hours of sleep a night. The

00:06:36.860 –> 00:06:40.620
family, the parent, 1 .8. So they’re all losing

00:06:40.620 –> 00:06:43.480
sleep, and that plays out throughout their life.

00:06:43.699 –> 00:06:48.060
We refer to comorbidities with ADHD. Well, one

00:06:48.060 –> 00:06:50.420
of our recent guidelines that we’ve published

00:06:50.420 –> 00:06:52.959
with the American Academy of Dermatology with

00:06:52.959 –> 00:06:56.860
regard to adult comorbidities, depression, anxiety,

00:06:57.300 –> 00:06:59.920
these things are more common in patients with

00:06:59.920 –> 00:07:02.500
moderate to severe disease. So I 100 % agree

00:07:02.500 –> 00:07:05.100
with what you’ve said. From a physical perspective,

00:07:05.339 –> 00:07:08.959
what are some of the specific clues or clinical

00:07:08.959 –> 00:07:10.899
signs that you’re dealing with someone with now

00:07:10.899 –> 00:07:13.500
severe atopic dermatitis rather than mild or

00:07:13.500 –> 00:07:16.490
moderate? Are there any? Yeah, for sure. So if

00:07:16.490 –> 00:07:19.589
we were doing a clinical trial, the sort of metrics

00:07:19.589 –> 00:07:22.889
in the EASI score, which is one of the eczema area

00:07:22.889 –> 00:07:25.189
and severity index, one of the things that we

00:07:25.189 –> 00:07:28.290
try to capture, the clinical signs are erythema,

00:07:28.430 –> 00:07:32.389
redness, papulation, bumpiness, excorations,

00:07:32.470 –> 00:07:34.850
scratch marks, and lichenification. That idea

00:07:34.850 –> 00:07:37.410
that the skin just looks like a hyperlinear,

00:07:37.490 –> 00:07:40.149
extra lines in the skin because it’s literally

00:07:40.149 –> 00:07:42.930
thickened almost like a callus in shoes that

00:07:42.930 –> 00:07:45.019
you wear that are too tight. And so those are

00:07:45.019 –> 00:07:47.319
the sort of signs that we look for. And then

00:07:47.319 –> 00:07:49.699
again, as we alluded a little bit earlier, that

00:07:49.699 –> 00:07:53.199
surface area, that quantity, that extent of involvement,

00:07:53.319 –> 00:07:55.199
we try to capture as well to put it all into

00:07:55.199 –> 00:07:58.660
a score. But all of these things sort of factor

00:07:58.660 –> 00:08:00.779
in. And you made a great point earlier where

00:08:00.779 –> 00:08:05.360
even some of the clinical metrics that we’re

00:08:05.360 –> 00:08:08.000
using don’t capture the extent of it. The EASI

00:08:08.000 –> 00:08:11.300
score, the most commonly used metric, does not

00:08:11.300 –> 00:08:16.860
include subjectives. It doesn’t include anything

00:08:16.860 –> 00:08:18.920
to do with what the patient’s actually feeling.

00:08:18.980 –> 00:08:21.420
So another one more commonly used in Europe,

00:08:21.420 –> 00:08:24.360
but oftentimes used in studies done here too,

00:08:24.459 –> 00:08:26.959
called a SCORAD, at least includes sleep loss

00:08:26.959 –> 00:08:31.079
and itch. So there is that. But all of these

00:08:31.079 –> 00:08:33.240
things factor into this sort of assessment that

00:08:33.240 –> 00:08:37.169
we make. How do you approach either… colonization

00:08:37.169 –> 00:08:40.490
or superinfection by a bacteria or in some cases

00:08:40.490 –> 00:08:43.450
a virus like eczema herpeticum it does that exist

00:08:43.450 –> 00:08:45.789
in your sort of clinical assessment as a standalone

00:08:45.789 –> 00:08:50.409
criteria or quality or do you use the presence

00:08:50.409 –> 00:08:54.309
of active infection to kick up the severity level

00:08:54.309 –> 00:08:58.450
or and or do you use the history of recurrent

00:08:58.450 –> 00:09:00.769
infections to change your severity level even

00:09:00.769 –> 00:09:03.210
though the kid might be mild in your in your

00:09:03.210 –> 00:09:06.679
exam room today, does that change the fact that

00:09:06.679 –> 00:09:09.759
you would consider repeated infections as making

00:09:09.759 –> 00:09:13.019
it more severe or less? Yeah, I do. I mean, those

00:09:13.019 –> 00:09:16.240
are really significant things that require significant

00:09:16.240 –> 00:09:18.720
interventions, whether it’s in the mildest end

00:09:18.720 –> 00:09:22.200
of the Staphylococcal bacterial infection spectrum

00:09:22.200 –> 00:09:27.139
using a topical antibiotic versus something like

00:09:27.139 –> 00:09:30.019
eczema herpeticum, which is a term we use to

00:09:30.019 –> 00:09:33.080
suggest that a child with eczema has a Herpes

00:09:33.080 –> 00:09:35.620
infection, which, you know, just to paint a picture,

00:09:35.779 –> 00:09:38.519
typically if we think about HSV-1, herpes simplex

00:09:38.519 –> 00:09:42.139
virus 1, a cold sore, quote unquote. right? Very

00:09:42.139 –> 00:09:45.200
common. You know, you get a recurrent spot on

00:09:45.200 –> 00:09:47.700
the lip. No one likes it. It is unpleasant for

00:09:47.700 –> 00:09:50.379
everyone, but oftentimes people just let it go

00:09:50.379 –> 00:09:52.759
and be untreated and it heals itself and may

00:09:52.759 –> 00:09:55.200
recur in that same spot, but not as impactful

00:09:55.200 –> 00:09:57.799
as it potentially could be. In a patient with

00:09:57.799 –> 00:10:01.039
eczema, for reasons we now know, there’s sort

00:10:01.039 –> 00:10:03.480
of an ability to fight off infections in their

00:10:03.480 –> 00:10:06.299
skin. Systemically, most kids with eczema, their

00:10:06.299 –> 00:10:10.179
immune systems are very healthy and robust, but

00:10:10.519 –> 00:10:13.960
In their skin, they have typically fewer what

00:10:13.960 –> 00:10:16.639
we call antimicrobial peptides, almost like nature’s

00:10:16.639 –> 00:10:19.740
mupirocin, something just sitting on the skin,

00:10:19.860 –> 00:10:22.379
helping us fight off infection. There’s less

00:10:22.379 –> 00:10:24.600
of it. They’re called beta-defensins or cathelicidins.

00:10:24.679 –> 00:10:27.200
There’s less of it in patients with atopic dermatitis.

00:10:27.360 –> 00:10:30.759
So they’re not as easily able to fight off bacterial

00:10:30.759 –> 00:10:33.639
infections, viral infections, and just sort of

00:10:33.639 –> 00:10:36.480
an interesting corollary. I always teach my residents,

00:10:36.740 –> 00:10:39.039
you know, they see patients with eczema and Staph

00:10:39.039 –> 00:10:41.240
superinfection. in the emergency department all

00:10:41.240 –> 00:10:43.990
the time because it’s so common. Almost never

00:10:43.990 –> 00:10:46.509
do they see a patient with psoriasis, another

00:10:46.509 –> 00:10:50.330
chronic T-cell-mediated immune rash of the

00:10:50.330 –> 00:10:53.250
skin. Almost never do you see them in the emergency

00:10:53.250 –> 00:10:55.309
room with a Staphylococcal superinfection. And

00:10:55.309 –> 00:10:57.590
that’s because their beta-defensins, their cathelicidins,

00:10:57.629 –> 00:11:02.529
their nature’s mupirocin or antibiotic is normal

00:11:02.529 –> 00:11:05.789
or upregulated, where in eczema, it’s less. And

00:11:05.789 –> 00:11:08.750
so there’s a very ready explanation for that.

00:11:08.830 –> 00:11:11.669
But 100%, if I see a kid who’s getting recurrent

00:11:11.669 –> 00:11:14.509
infection, even if – maybe by other metrics, they’re

00:11:14.509 –> 00:11:17.110
more mild – we’re going to think about maybe not

00:11:17.110 –> 00:11:18.909
only in our own mind and trying to make that

00:11:18.909 –> 00:11:20.529
patient better, which is really what we’re trying

00:11:20.529 –> 00:11:23.429
to do, but trying to document and justify if

00:11:23.429 –> 00:11:25.529
we feel they need more aggressive medications,

00:11:25.710 –> 00:11:28.049
which we’ll talk about the medication things

00:11:28.049 –> 00:11:30.789
a little bit later, I think. We’re going to need

00:11:30.789 –> 00:11:33.250
to document that and say, hey, look, this is

00:11:33.250 –> 00:11:35.409
their easy score, but hey, they’ve had two Staph

00:11:35.409 –> 00:11:37.309
infections. They’ve had an eczema herpeticum.

00:11:37.389 –> 00:11:39.830
This is something we need to address, and we

00:11:39.830 –> 00:11:41.990
may need more aggressive medicines to do it.

00:11:42.250 –> 00:11:46.450
How do you use the medicines or I should say

00:11:46.450 –> 00:11:48.049
maybe interventions, because that’s a little

00:11:48.049 –> 00:11:50.629
bit more general, that the patient has tried

00:11:50.629 –> 00:11:54.830
in the past as a way to either change or upgrade

00:11:54.830 –> 00:11:57.429
their severity? Does that make sense? Do you

00:11:57.429 –> 00:12:02.330
get what I’m asking? Yeah, for sure. And it’s

00:12:02.330 –> 00:12:05.289
an important discussion because I guess by definition,

00:12:05.289 –> 00:12:07.909
if we’re talking about this particular type of

00:12:07.909 –> 00:12:11.700
patient, something’s not going well. Either their

00:12:11.700 –> 00:12:16.279
eczema is not responding as we had hoped or they’re

00:12:16.279 –> 00:12:19.360
getting superinfections. Either of those things

00:12:19.360 –> 00:12:22.240
are not good and we need to figure out why. And

00:12:22.240 –> 00:12:25.320
so if, let’s take an example of, to answer your

00:12:25.320 –> 00:12:27.679
specific question, this is a patient who’s used

00:12:27.679 –> 00:12:31.679
2 .5 % hydrocortisone and they come in to see

00:12:31.679 –> 00:12:33.720
you and they say, I’m not getting better. Or

00:12:33.720 –> 00:12:35.240
you can see they’re not getting better. They’ve

00:12:35.240 –> 00:12:37.240
had infections. Well, the first thing you want

00:12:37.240 –> 00:12:39.440
to make sure is, are they actually using it?

00:12:40.019 –> 00:12:44.500
Because that’s a huge issue. I mean, none of

00:12:44.500 –> 00:12:48.460
us are perfect with medicine adherence. Not a

00:12:48.460 –> 00:12:51.679
single person. Not present company included.

00:12:51.840 –> 00:12:53.940
Not anyone probably listening to this podcast.

00:12:55.019 –> 00:12:58.460
But it’s even harder for a patient who has to

00:12:58.460 –> 00:13:02.200
do something. daily, topical, not very pleasant

00:13:02.200 –> 00:13:05.039
for many folks to adhere. So there’s literally

00:13:05.039 –> 00:13:08.799
the challenges of adhering. And then there’s

00:13:08.799 –> 00:13:11.139
the fear, potentially, of some of the medications

00:13:11.139 –> 00:13:14.120
we prescribe. And if we don’t address those fears

00:13:14.120 –> 00:13:18.960
and bring them out and give proper space for

00:13:18.960 –> 00:13:22.019
the parents to explain their fears and then address

00:13:22.019 –> 00:13:25.059
them, maybe or maybe not reassure them. But if

00:13:25.059 –> 00:13:26.940
you don’t reassure them, you would know that

00:13:26.940 –> 00:13:29.230
that’s a problem so you can move on. on to a

00:13:29.230 –> 00:13:32.070
different medication. But those are the sorts

00:13:32.070 –> 00:13:34.409
of things I think, Andrew, to answer your question,

00:13:34.470 –> 00:13:38.470
that I try to think about when I see a patient

00:13:38.470 –> 00:13:41.809
in that context. Do you have any tips or tricks

00:13:41.809 –> 00:13:43.590
for how you assess if the patient’s actually

00:13:43.590 –> 00:13:46.629
using the medicines that you give them? Well,

00:13:46.690 –> 00:13:50.679
first of all, I will… Ask them. I mean, in

00:13:50.679 –> 00:13:53.000
a study, in a clinical trial, we’ll weigh tubes,

00:13:53.240 –> 00:13:56.360
right? So we will actually weigh the tubes, have

00:13:56.360 –> 00:14:00.980
them bring them back, weigh them, and see. In

00:14:00.980 –> 00:14:05.799
a regular clinic visit, it really is my biggest…

00:14:06.860 –> 00:14:10.799
tip or trick with regard, let’s just talk specifically

00:14:10.799 –> 00:14:12.960
about topical steroids now. We may be getting

00:14:12.960 –> 00:14:16.919
ahead of ourselves, but my biggest tip there

00:14:16.919 –> 00:14:20.360
is, number one, to not be dismissive of those

00:14:20.360 –> 00:14:25.070
concerns. Hopefully, before I ever prescribe

00:14:25.070 –> 00:14:27.509
them, I’ve gone through, number one, this is

00:14:27.509 –> 00:14:30.870
a topical steroid that have been around for 75 years.

00:14:31.090 –> 00:14:33.029
We’ve got a ton of experience with them. They

00:14:33.029 –> 00:14:36.009
are not the steroids that you see banned from

00:14:36.009 –> 00:14:38.090
professional sports leagues. This is a very,

00:14:38.129 –> 00:14:43.059
very different thing. So I start there. And then

00:14:43.059 –> 00:14:45.179
I’ll go, okay, what are we worried about? And

00:14:45.179 –> 00:14:47.100
depending on the age of the child, if it’s a

00:14:47.100 –> 00:14:50.000
two-month-old preemie, I may very much be worried

00:14:50.000 –> 00:14:52.240
about the absorption and what’s going inside

00:14:52.240 –> 00:14:54.759
of the topical steroid. So we’ll talk about that

00:14:54.759 –> 00:14:57.990
and how we mitigate that risk. More often, it’s

00:14:57.990 –> 00:15:02.370
an older child with maybe focal atopic dermatitis

00:15:02.370 –> 00:15:05.830
patches and plaques and itchy areas. And I’ll

00:15:05.830 –> 00:15:09.009
say, listen, this two-year, four- or five-year

00:15:09.009 –> 00:15:11.110
-old child, you know, one of their hands, not

00:15:11.110 –> 00:15:13.429
my hand, one of THEIR hands is 1% of THEIR body

00:15:13.429 –> 00:15:15.549
surface area. Let’s say they have it on both

00:15:15.549 –> 00:15:19.049
elbows, both knees. That’s what? Barely 2%, 3

00:15:19.049 –> 00:15:21.149
% of their body surface area. They are not going

00:15:21.149 –> 00:15:23.950
to absorb enough to matter inside. So let’s not

00:15:23.950 –> 00:15:26.759
worry about that. But then there like, what about

00:15:26.759 –> 00:15:29.720
thinning of the skin? They’ve always heard, oh

00:15:29.720 –> 00:15:31.639
God, topical steroids can thin the skin and they

00:15:31.639 –> 00:15:34.639
can. But if that’s where you leave it, they’ve

00:15:34.639 –> 00:15:37.159
read that online. They’ve heard that from their

00:15:37.159 –> 00:15:38.779
topical, from their topical steroid. They’ve

00:15:38.779 –> 00:15:41.919
heard that from their pediatrician. If that’s

00:15:41.919 –> 00:15:44.549
where you leave it. You know, what is that? Is

00:15:44.549 –> 00:15:48.289
that bad? Does it go away? So what I try to do

00:15:48.289 –> 00:15:50.610
with that is I will take them through what it

00:15:50.610 –> 00:15:53.009
is and say, first of all, for the reasons we’re

00:15:53.009 –> 00:15:54.470
talking about it, we’re going to use the right

00:15:54.470 –> 00:15:56.649
strength in the right areas for the right amount

00:15:56.649 –> 00:15:59.129
of time. So what we’re about to describe is never

00:15:59.129 –> 00:16:02.509
going to happen. But just in case, here’s what

00:16:02.509 –> 00:16:04.620
it would look like. And oftentimes on a little

00:16:04.620 –> 00:16:07.059
baby, because that’s where fears are most acute

00:16:07.059 –> 00:16:09.740
for parents, especially providers too. I’ll point

00:16:09.740 –> 00:16:12.659
to the temple because the temple is an area where

00:16:12.659 –> 00:16:14.639
it rarely gets eczema. So they haven’t used any

00:16:14.639 –> 00:16:17.259
topical steroids there. And every baby, the skin

00:16:17.259 –> 00:16:19.620
is just very tight. And so you can see a little

00:16:19.620 –> 00:16:22.500
vein traversing that area, which is a little

00:16:22.500 –> 00:16:24.460
more subtle than if you look through your wrist

00:16:24.460 –> 00:16:26.340
or my wrist or other areas where you can always

00:16:26.340 –> 00:16:28.460
see veins. And I’ll say, so if you see something

00:16:28.460 –> 00:16:32.830
like that here. Or here, pointing to my cheek

00:16:32.830 –> 00:16:35.870
or my elbow, places where you hadn’t seen that

00:16:35.870 –> 00:16:39.169
vein before. Perhaps that’s the first sign of

00:16:39.169 –> 00:16:40.750
thinning of the skin. Well, guess what? It’s

00:16:40.750 –> 00:16:44.389
entirely reversible. So I kind of take them through

00:16:44.389 –> 00:16:47.509
that so they know that there’s not this condition

00:16:47.509 –> 00:16:50.429
that they hope and expect and have been told

00:16:50.429 –> 00:16:53.090
will get better with time. And then they create

00:16:53.090 –> 00:16:56.399
a problem that won’t. So I try to let them know,

00:16:56.440 –> 00:16:59.480
kind of empower them to be able to see what that

00:16:59.480 –> 00:17:02.240
thing they’re so worried about is at a time when

00:17:02.240 –> 00:17:05.400
we can all recover from it. I totally agree.

00:17:05.519 –> 00:17:08.160
I do everything that you just said. And then

00:17:08.160 –> 00:17:11.579
if I’m lucky, quote unquote, the patient has

00:17:11.579 –> 00:17:13.539
some lichenification, some thickening of the

00:17:13.539 –> 00:17:16.920
skin. This is exactly what we’re trying to treat.

00:17:17.299 –> 00:17:20.259
So in a way, one of the potential side effects

00:17:20.259 –> 00:17:23.900
is going to actually be used. for good, and we’re

00:17:23.900 –> 00:17:26.240
going to thin that skin back to normal, we’re

00:17:26.240 –> 00:17:28.799
not going to go past normal, right? And then

00:17:28.799 –> 00:17:31.539
I always talk about how it’s different around

00:17:31.539 –> 00:17:34.099
or on the eyelids, around the eyes, on the eyelids,

00:17:34.180 –> 00:17:36.640
that can cause other problems separate from thinning

00:17:36.640 –> 00:17:39.640
of the skin. Your child doesn’t have any need

00:17:39.640 –> 00:17:41.940
to put a topical steroid anywhere near their

00:17:41.940 –> 00:17:46.259
eyes, you know, so don’t, right? What I’ve found

00:17:46.259 –> 00:17:50.319
probably two things that have really kind of

00:17:50.319 –> 00:17:53.710
changed the way I talk with my patients in the

00:17:53.710 –> 00:17:55.950
exam room one actually I have to give credit

00:17:55.950 –> 00:17:59.230
where credit’s due my former colleague, mentor

00:17:59.230 –> 00:18:03.690
Larry Eichenfield, MD used to make them bring their

00:18:03.690 –> 00:18:07.750
tubes in physically and it might be a 30-gram

00:18:07.750 –> 00:18:09.990
tube it might be a 15-gram tube – geez you would

00:18:09.990 –> 00:18:12.490
hope not – but usually it’s a 30- or 60-gram tube

00:18:12.490 –> 00:18:15.210
and he would say okay first off to your point

00:18:15.690 –> 00:18:17.329
“How come this hasn’t been opened yet, right?”

00:18:18.109 –> 00:18:20.630
Well, I just got it refilled. That’s a lot different

00:18:20.630 –> 00:18:23.490
than you’ve had this for three months and you’re

00:18:23.490 –> 00:18:25.349
telling me nothing’s working. This is the first

00:18:25.349 –> 00:18:28.750
tube. You haven’t refilled it once and the seal’s

00:18:28.750 –> 00:18:31.069
not even broken on it, right? So that reframes

00:18:31.069 –> 00:18:33.710
the conversation. But more often than not, it’s

00:18:33.710 –> 00:18:37.109
open and something’s been removed from it. But

00:18:37.109 –> 00:18:41.410
you can say, okay, I expect you to use this medicine.

00:18:42.280 –> 00:18:44.359
once or twice a day. Are you a, are you a two

00:18:44.359 –> 00:18:46.759
times a day guy or one time a day guy? Generally

00:18:46.759 –> 00:18:49.380
twice a day twice at it. Me too. So, twice a day

00:18:49.380 –> 00:18:52.000
and in general depending of course what strength

00:18:52.000 –> 00:18:53.880
I’m using like I don’t really want you to use

00:18:53.880 –> 00:18:56.720
it more than two weeks without at least letting

00:18:56.720 –> 00:18:58.559
me know if something something’s probably not

00:18:58.559 –> 00:19:00.420
right if you have to keep using this medicine

00:19:00.420 –> 00:19:02.680
more than two weeks and you’re not getting any

00:19:02.680 –> 00:19:05.200
effect and I’ll couch that and say, you know

00:19:05.200 –> 00:19:07.059
if it’s if it’s almost clear and you’re hitting

00:19:07.059 –> 00:19:10.819
day 14 go ahead and use it until until 15 or

00:19:10.819 –> 00:19:14.400
16 and you’re fine. But how much of this medicine

00:19:14.400 –> 00:19:16.599
do you think, using this tube as your example,

00:19:16.680 –> 00:19:18.819
how much of the medicine do you expect to go

00:19:18.819 –> 00:19:22.240
through in those two weeks? And I’ve found that

00:19:22.240 –> 00:19:25.440
I’m 100% shocked that they might say, oh, a

00:19:25.440 –> 00:19:28.579
quarter of the tube, of a 30-gram tube. Well,

00:19:28.599 –> 00:19:33.119
no, your child’s 12 years old. 60 kilograms.

00:19:33.319 –> 00:19:35.200
You’re going to be going through two 30-gram

00:19:35.200 –> 00:19:38.640
tubes pretty easily. And oh, wow, I’d never really

00:19:38.640 –> 00:19:40.940
thought of it that way. So physically telling

00:19:40.940 –> 00:19:44.299
them, I want you to go through this tube in one

00:19:44.299 –> 00:19:46.160
week, of course, depending on the size of the

00:19:46.160 –> 00:19:48.660
tube again, but that’s the amount of medicine

00:19:48.660 –> 00:19:51.579
I expect you to be using on a weekly basis, I’ve

00:19:51.579 –> 00:19:54.420
found to be very powerful. And then I also, I’ve

00:19:54.420 –> 00:19:56.480
learned from the way I’ve written prescriptions,

00:19:56.539 –> 00:19:59.299
I’ve always tried to write using no abbreviations.

00:19:59.359 –> 00:20:02.640
I hate abbreviations. And I think it’s just confusing

00:20:02.640 –> 00:20:07.640
to say A -A -A -B -I -D -X -2 -W -K -S. Apply

00:20:07.640 –> 00:20:10.099
to affected area twice a day for two weeks. That

00:20:10.099 –> 00:20:12.440
doesn’t mean anything to anybody except the pharmacist.

00:20:13.200 –> 00:20:16.059
So I’ll write out pretty detailed instructions,

00:20:16.279 –> 00:20:19.180
including I want you to take a week off between

00:20:19.180 –> 00:20:22.500
using. And what I’ve learned is that’s the message

00:20:22.500 –> 00:20:25.539
was lost. If you’re using it on your LEFT elbow

00:20:25.539 –> 00:20:29.319
crease, for example, in my mind, it’s still quite

00:20:29.529 –> 00:20:31.869
reasonable to use it on your RIGHT elbow crease

00:20:31.869 –> 00:20:35.490
if a new rash flare pops out or behind your knee

00:20:35.490 –> 00:20:37.390
or wherever you might use it but I’ve learned

00:20:37.390 –> 00:20:39.329
from my patients that they said, “Oh, well you told

00:20:39.329 –> 00:20:42.150
me not to use the medicine for that week” and

00:20:42.150 –> 00:20:45.150
then they’ll just let any new flare go untreated

00:20:45.150 –> 00:20:47.509
for seven days and I missed that opportunity.

00:20:47.509 –> 00:20:50.230
That’s on me. That’s just poor instruction. Have

00:20:50.230 –> 00:20:52.750
you ever had anything like that pop up with your

00:20:52.750 –> 00:20:57.259
patients? Oh, for sure. And it’s just remarkable

00:20:57.259 –> 00:21:00.099
how many times they’ll come into a new visit,

00:21:00.240 –> 00:21:04.819
and they’ll say, “Okay, this triamcinolone, for

00:21:04.819 –> 00:21:08.579
instance, works really well, but I was told I

00:21:08.579 –> 00:21:10.559
could only use it for 15 days out of the month.”

00:21:10.880 –> 00:21:13.279
And eczema is not a “15 days out of the month”

00:21:13.279 –> 00:21:15.660
proposition. And so you have to figure out how

00:21:15.660 –> 00:21:19.799
to… I will always say, I will never say, “Oh,

00:21:19.819 –> 00:21:21.839
that silly pediatrician, They don’t know what

00:21:21.839 –> 00:21:24.720
they’re talking about.” I’ll say I 100 % agree

00:21:24.720 –> 00:21:26.559
with that. What they’re trying to communicate

00:21:26.559 –> 00:21:30.440
there is that you need to take breaks. But let’s

00:21:30.440 –> 00:21:33.839
just delve into that a little further. Exactly

00:21:33.839 –> 00:21:35.740
what you said in terms of different locations

00:21:35.740 –> 00:21:40.160
is one element of it. Knowing also that there

00:21:40.160 –> 00:21:42.059
are going to be times where they need to use

00:21:42.059 –> 00:21:45.900
it a little longer. Their child catches a cold,

00:21:46.000 –> 00:21:48.940
runny nose, whatever, seemingly having nothing

00:21:48.940 –> 00:21:51.160
to do with the skin. Well, it’s immune stimulation,

00:21:51.359 –> 00:21:53.440
right? Your immune system is going to rev up

00:21:53.440 –> 00:21:57.259
to get that virus gone, and that stimulates the

00:21:57.259 –> 00:21:59.019
eczema. And so they may have an eczema flare

00:21:59.019 –> 00:22:01.460
in the wake of a cold that makes them have to

00:22:01.460 –> 00:22:03.470
have this burst of… treatment for a little

00:22:03.470 –> 00:22:07.470
bit longer to kind of calm things down so all

00:22:07.470 –> 00:22:10.130
of those things I 100 % agree with especially

00:22:10.130 –> 00:22:15.720
the idea of oftentimes how far a medicine will

00:22:15.720 –> 00:22:18.200
be able to go and how much they should use. Sometimes

00:22:18.200 –> 00:22:20.099
see them come in with these tiny, not even 15

00:22:20.099 –> 00:22:22.640
grams, these tiny little sample sizes, and that’s

00:22:22.640 –> 00:22:24.740
all they were given. And boy, it worked well

00:22:24.740 –> 00:22:27.059
on that one square centimeter of my skin, but

00:22:27.059 –> 00:22:29.599
probably not going to make a huge difference.

00:22:29.839 –> 00:22:32.279
And then the last thing I’ll say is, as you well

00:22:32.279 –> 00:22:35.440
know, frequently eczema, when it gets better,

00:22:35.680 –> 00:22:38.720
heals with some dispigmentation, some discoloration,

00:22:38.920 –> 00:22:40.799
sometimes a little lighter, sometimes a little

00:22:40.799 –> 00:22:43.319
darker. And I think there are two really important

00:22:43.319 –> 00:22:47.180
messages there involved with that is number one,

00:22:47.339 –> 00:22:50.519
if you, and many parents do, will sort of carefully

00:22:50.519 –> 00:22:53.400
parse the adverse effects of topical steroids,

00:22:53.559 –> 00:22:55.779
one of which can say can cause discoloration

00:22:55.779 –> 00:22:59.579
and hypopigmentation, and it can, but it’s also

00:22:59.579 –> 00:23:01.720
really important to remember and much more common

00:23:01.720 –> 00:23:04.960
that the skin, the eczema is healing and it’s

00:23:04.960 –> 00:23:08.200
that inflammation itself that the eczema, that’s

00:23:08.200 –> 00:23:11.569
what eczema is, that is causing that. temporary

00:23:11.569 –> 00:23:14.430
not permanent discoloration and so i always want

00:23:14.430 –> 00:23:15.990
to make sure that they realize that that’s not

00:23:15.990 –> 00:23:19.890
a side effect of of the the topical steroid and

00:23:19.890 –> 00:23:22.670
then further on the other side of things is is

00:23:22.670 –> 00:23:25.509
getting at not using too much with regard to

00:23:25.509 –> 00:23:28.789
this discoloration is unless you tell parents

00:23:28.789 –> 00:23:32.069
it doesn’t look normal right that examine heals

00:23:32.069 –> 00:23:35.940
and it looks abnormal. It’s discolored. And yet

00:23:35.940 –> 00:23:39.799
it’s not inflamed anymore. It’s flat. It’s smooth.

00:23:40.000 –> 00:23:43.099
It’s not itchy. It’s not red. And so what I’ll

00:23:43.099 –> 00:23:46.480
tell parents is, is if it’s not bumpy, it’s not

00:23:46.480 –> 00:23:50.640
red, it’s not itchy, just moisturize it. That’s

00:23:50.640 –> 00:23:53.160
just your healed eczema. And if you keep treating

00:23:53.160 –> 00:23:55.779
with a topical steroid to that, yeah, you may,

00:23:55.900 –> 00:23:57.700
number one, you don’t need it. And number two,

00:23:57.759 –> 00:24:00.000
you are increasing the risk that you might actually

00:24:00.000 –> 00:24:03.599
cause a side effect. 100 % agree. I try to use

00:24:03.599 –> 00:24:06.940
proactively the hypopigmentation, usually is

00:24:06.940 –> 00:24:09.539
what I’m saying, as a sign you did your job.

00:24:09.700 –> 00:24:11.619
I mean, you knocked out the red, rough, itchy

00:24:11.619 –> 00:24:14.019
spots. If you can feel it, it’s still flaring,

00:24:14.019 –> 00:24:17.660
but a flat, paler skin is where that inflammation

00:24:17.660 –> 00:24:19.880
was. i don’t know if you have a spiel but i basically

00:24:19.880 –> 00:24:23.680
say the inflammation sort of “stuns” or “makes the

00:24:23.680 –> 00:24:27.079
cells that make your tan lazy” and they don’t,

00:24:27.079 –> 00:24:28.900
they’re not working like they should

00:24:28.900 –> 00:24:31.559
it takes i don’t know i tell usually about anywhere

00:24:31.559 –> 00:24:34.079
up to a year even a little longer sometimes for

00:24:34.079 –> 00:24:36.849
that to come back totally normal but the point

00:24:36.849 –> 00:24:40.089
is it should come back normally and you did what

00:24:40.089 –> 00:24:42.430
you needed to do to make sure that it’s now that

00:24:42.430 –> 00:24:45.130
timer has been started and you know you would

00:24:45.130 –> 00:24:47.890
expect the color going to be back hopefully by

00:24:47.890 –> 00:24:49.569
next summer and it’s going to get well that’s

00:24:49.569 –> 00:24:51.430
another good point it’s going to get worse you’re

00:24:51.430 –> 00:24:54.009
going to see this more in the summer months because

00:24:54.009 –> 00:24:56.150
the contrast around those spots is different

00:24:56.150 –> 00:24:57.970
and then the winter is going to be a little bit

00:24:57.970 –> 00:24:59.569
more blended in because you don’t get that tan.

00:24:59.569 –> 00:25:03.349
so yeah I totally agree, and I’ll leverage that

00:25:03.349 –> 00:25:06.849
further to sort of squeeze in yet another dermatologist

00:25:06.849 –> 00:25:09.369
message, which is if you go out in the summer,

00:25:09.470 –> 00:25:12.049
for the exact reasons you said, the quote -unquote

00:25:12.049 –> 00:25:15.549
normal skin tans normally, and the dispigmented,

00:25:15.589 –> 00:25:19.069
sort of hypopigmented skin doesn’t, and so the

00:25:19.069 –> 00:25:22.609
contrast makes it look worse. So therefore, sunscreen

00:25:22.609 –> 00:25:26.390
will actually help you minimize that apparent

00:25:26.390 –> 00:25:29.710
worsening in the summer with sun exposure. For

00:25:29.710 –> 00:25:32.809
that, for hypopigmentation related to post inflammation,

00:25:33.230 –> 00:25:36.390
I’m almost always saying I prescribe, quote unquote,

00:25:36.710 –> 00:25:39.390
you a combination moisturizer sunscreen. And

00:25:39.390 –> 00:25:42.349
there’s a couple out there. But you pick one

00:25:42.349 –> 00:25:44.490
of these three or four products is going to work.

00:25:44.549 –> 00:25:46.450
And that’s exactly what you need. It’s got sunscreen

00:25:46.450 –> 00:25:49.309
built in and it’s moisturizing your skin. Maybe

00:25:49.309 –> 00:25:51.650
I give them a little break from using something

00:25:51.650 –> 00:25:53.369
thick during the summer that I would normally

00:25:53.369 –> 00:25:55.549
have them being used in the winter. But that

00:25:55.549 –> 00:26:00.079
works great. In this day and age of TikTok, unfortunately,

00:26:00.119 –> 00:26:03.799
becoming some people’s main source for education,

00:26:04.059 –> 00:26:08.420
are you seeing the concept of topical steroid

00:26:08.420 –> 00:26:11.079
withdrawal percolate into your clinic yet? Is

00:26:11.079 –> 00:26:14.440
that a thing or have you managed to dodge that

00:26:14.440 –> 00:26:17.420
bullet? Well, I’ll say first of all, Andrew,

00:26:17.500 –> 00:26:20.559
I have to send a thank you note to you because

00:26:20.559 –> 00:26:26.440
I am a complete social media Luddite. And no

00:26:26.440 –> 00:26:29.779
Facebook, not even Doximity, none of that stuff.

00:26:29.880 –> 00:26:33.200
And my 18-year-old daughter is eternally embarrassed

00:26:33.200 –> 00:26:36.920
at my naivete around these things. And so when

00:26:36.920 –> 00:26:38.819
I told her I was doing a podcast with her, I

00:26:38.819 –> 00:26:42.279
got so much credit. A podcast with you. I got

00:26:42.279 –> 00:26:44.400
so much credit with her. So thank you for that.

00:26:45.660 –> 00:26:49.160
No problem. You are absolutely right. It is a

00:26:49.160 –> 00:26:55.549
source of information that is accessible. to

00:26:55.549 –> 00:26:57.769
families and patients. And it’s interesting and

00:26:57.769 –> 00:27:00.529
it’s engaging. And there is some good content

00:27:00.529 –> 00:27:02.789
in there. My daughter has shared some of that

00:27:02.789 –> 00:27:06.569
to sort of tell me it’s not all bad, but it’s

00:27:06.569 –> 00:27:12.569
also unregulated. And goodness knows, what could

00:27:12.569 –> 00:27:16.609
potentially be out there that’s potentially a

00:27:16.609 –> 00:27:21.569
challenge. And you mentioned one area of… controversy.

00:27:21.569 –> 00:27:24.430
The idea of topical steroid withdrawal, which

00:27:24.430 –> 00:27:27.250
I have no doubt is on TikTok. I haven’t seen

00:27:27.250 –> 00:27:30.710
those things, but I’m very aware of the problem.

00:27:30.910 –> 00:27:35.430
And yes, I have encountered it. I use the word

00:27:35.430 –> 00:27:37.750
controversial because there are folks who don’t

00:27:37.750 –> 00:27:41.329
think it exists. I’m not one of those folks,

00:27:41.369 –> 00:27:45.109
though I also am not sure I’ve ever seen it in

00:27:45.109 –> 00:27:48.579
a kid. I’ll say that. I 100 % agree. That’s actually

00:27:48.579 –> 00:27:51.039
really funny because that’s been my experience.

00:27:51.220 –> 00:27:54.279
I’ve seen it in adults. I distinctly remember

00:27:54.279 –> 00:27:58.579
a woman who had been treated for her facial rosacea.

00:27:59.140 –> 00:28:02.220
You wouldn’t believe this, I think, but beta

00:28:02.220 –> 00:28:05.160
methasone – ultra potent steroid – twice a day,

00:28:05.299 –> 00:28:08.720
every day for two years. On the face. On her

00:28:08.720 –> 00:28:12.990
face. She came in with… the largest blood vessels

00:28:12.990 –> 00:28:16.690
that you could see and she had stopped her steroid

00:28:16.690 –> 00:28:20.170
and now was on top of that background of blood

00:28:20.170 –> 00:28:23.289
vessels she had what looked like a demodex infection

00:28:23.289 –> 00:28:26.289
it didn’t turn out that it was but just hundreds

00:28:26.289 –> 00:28:29.849
of pustules all over her face and I thought well

00:28:29.849 –> 00:28:32.450
geez that’s probably what topical steroid withdrawal

00:28:32.450 –> 00:28:34.869
looks like but I’ve never seen it in a child

00:28:34.869 –> 00:28:37.400
and I don’t know if that’s because I don’t think

00:28:37.400 –> 00:28:39.539
it’s because kids are something special that

00:28:39.539 –> 00:28:42.039
they couldn’t get it. I just think we’re smarter

00:28:42.039 –> 00:28:44.960
about how we use the products. Is that fair or

00:28:44.960 –> 00:28:47.299
is that crazy? I think it is fair. And I think

00:28:47.299 –> 00:28:49.500
the other thing that sort of factors into that

00:28:49.500 –> 00:28:53.099
is non-dermatologists. And this could be a problem

00:28:53.099 –> 00:28:55.920
at the hands of a dermatologist, a non-dermatologist.

00:28:56.099 –> 00:28:59.400
But I think non-dermatologists are also much,

00:28:59.559 –> 00:29:04.019
much leerier. of using a very potent steroid

00:29:04.019 –> 00:29:06.980
in a child than they might be in an adult. And

00:29:06.980 –> 00:29:10.119
so I think that is the issue, is using extremely

00:29:10.119 –> 00:29:12.700
potent steroids, oftentimes on the face, the

00:29:12.700 –> 00:29:15.200
exact scenario you described, where I very much

00:29:15.200 –> 00:29:17.839
think it’s a real thing because I attend conferences

00:29:17.839 –> 00:29:21.980
and all sorts of things where I see these patients

00:29:21.980 –> 00:29:26.339
presented, they just aren’t my own. And it’s

00:29:26.339 –> 00:29:30.289
difficult because there are no diagnostic

00:29:30.289 –> 00:29:32.650
criteria. There are efforts being made to change

00:29:32.650 –> 00:29:37.430
that, but it’s a challenging scenario. And I’m

00:29:37.430 –> 00:29:41.910
sure that TikTok can, hopefully there are some

00:29:41.910 –> 00:29:44.410
sites on TikTok that maybe have some sensible

00:29:44.410 –> 00:29:46.549
ideas about it, but I’m sure it can also potentially

00:29:46.549 –> 00:29:49.750
fan the flames of controversy. Is it fair to

00:29:49.750 –> 00:29:53.279
say, though, if you used… hydrocortisone 2

00:29:53.279 –> 00:29:57.180
.5 % ointment or triamcinolone 0 .1 % ointment

00:29:57.180 –> 00:30:00.779
of medium strength. Even the one that I’ll use

00:30:00.779 –> 00:30:03.759
probably as my strongest quote -unquote go -to

00:30:03.759 –> 00:30:07.319
would be fluocinonide ointment. I’m very rarely

00:30:07.319 –> 00:30:10.059
using clobetasol. And if I do, it’s on the hands

00:30:10.059 –> 00:30:12.819
or feet or very thick area, very short limited

00:30:12.819 –> 00:30:15.200
amount of time. But those are kind of the three

00:30:15.200 –> 00:30:18.160
steroids that I’ll use on a stepwise approach.

00:30:19.220 –> 00:30:24.240
Any three… used twice a day for two weeks appropriately,

00:30:24.559 –> 00:30:27.960
would you ever expect to see the condition of

00:30:27.960 –> 00:30:30.859
“topical steroid withdrawal” associated with that

00:30:30.859 –> 00:30:33.079
clinical scenario? Does that exist in your mind

00:30:33.079 –> 00:30:35.859
as a possibility? Haven’t we been taught never

00:30:35.859 –> 00:30:37.380
to say “never” in medicine? Well, I’m going to

00:30:37.380 –> 00:30:40.819
say “never.” Okay. Yeah, I agree. That’s a NEVER.

00:30:42.209 –> 00:30:44.430
Unless, I don’t even think if you could eat it,

00:30:44.470 –> 00:30:47.690
I don’t think you could even get, maybe the Lidex,

00:30:47.690 –> 00:30:49.549
maybe the fluocinonide and you might be able to

00:30:49.549 –> 00:30:52.430
do some sort of adrenal suppression, but I, geez,

00:30:52.509 –> 00:30:54.369
I just don’t think it could. I don’t think it

00:30:54.369 –> 00:30:56.990
could do it. No, I agree with you. Well, one

00:30:56.990 –> 00:30:59.269
other aspect that I find always interesting from

00:30:59.269 –> 00:31:01.630
an investigative perspective is when you have

00:31:01.630 –> 00:31:04.390
a severe eczema patient and I’ll put eczema in

00:31:04.390 –> 00:31:06.730
quotes on this one and you’ve been treating them

00:31:06.730 –> 00:31:09.170
like they have atopic dermatitis and everything

00:31:09.170 –> 00:31:13.069
you’re doing is. has been tried, done correctly,

00:31:13.309 –> 00:31:17.089
not working, when do you take a step back and

00:31:17.089 –> 00:31:19.750
say, geez, could this be a hypersensitivity reaction?

00:31:19.990 –> 00:31:22.190
Could this be an allergic contact dermatitis?

00:31:22.789 –> 00:31:26.930
Are there clues? Yeah, and just an important

00:31:26.930 –> 00:31:29.089
thing to have in the back of your mind always.

00:31:29.720 –> 00:31:32.400
because it’s so easy for us to say, oh, must

00:31:32.400 –> 00:31:37.519
be non -adherence to the medicine, must be, there

00:31:37.519 –> 00:31:40.079
must be an allergen in the environment that we’re

00:31:40.079 –> 00:31:43.359
just missing, must be something, something. Well…

00:31:43.690 –> 00:31:46.069
Step back. Exactly what you said. Step back and

00:31:46.069 –> 00:31:47.890
make sure, okay, could this be something else?

00:31:49.390 –> 00:31:53.230
We actually, just as part of our American Academy

00:31:53.230 –> 00:31:55.630
of Dermatology Atopic Dermatitis Guidelines Committee

00:31:55.630 –> 00:31:57.750
have just, it’s not published yet, but it will

00:31:57.750 –> 00:32:02.130
be in the next few months, put out a guideline

00:32:02.130 –> 00:32:06.809
for adults with this exact scenario. What do

00:32:06.809 –> 00:32:09.730
you do? What do you think of when things aren’t

00:32:09.730 –> 00:32:12.839
going as they should? diagnostically so that’s

00:32:12.839 –> 00:32:15.279
specifically what where where do you go what

00:32:15.279 –> 00:32:18.579
do you think of and so um That absolutely is

00:32:18.579 –> 00:32:20.140
something you should think of because there are

00:32:20.140 –> 00:32:23.299
a number of things that can mimic atopic dermatitis.

00:32:23.420 –> 00:32:25.539
In the pediatric population, it can range from

00:32:25.539 –> 00:32:28.619
infestations like scabies to contact allergy,

00:32:28.799 –> 00:32:31.000
less common in kids and adults, but absolutely

00:32:31.000 –> 00:32:35.359
potentially a problem, to even some more severe

00:32:35.359 –> 00:32:38.880
or more significant conditions. So that is what

00:32:38.880 –> 00:32:42.289
I think of. You sort of go through, okay. Let’s

00:32:42.289 –> 00:32:44.509
step back. They’re diagnostic criteria. We don’t

00:32:44.509 –> 00:32:46.789
use them much, but they exist, and they’re wonderful

00:32:46.789 –> 00:32:49.549
to be able to fall back on. Is there a family

00:32:49.549 –> 00:32:51.630
history here? Does this itch? Is it in the proper

00:32:51.630 –> 00:32:54.069
distribution? Does it wax and wane? Then you

00:32:54.069 –> 00:32:57.170
can go through minor diagnostic criteria. Kind

00:32:57.170 –> 00:32:59.430
of go through all of those things in your mind,

00:32:59.490 –> 00:33:01.869
and then do appropriate tests if you need to.

00:33:02.029 –> 00:33:04.549
Scrape the skin looking for a fungal infection

00:33:04.549 –> 00:33:07.890
or for scabies. Biopsy if you need to. We don’t

00:33:07.890 –> 00:33:11.250
often, but it is potentially a viable way to

00:33:11.250 –> 00:33:13.720
get. more information. So all of those things

00:33:13.720 –> 00:33:15.779
need to be considered and potentially explored

00:33:15.779 –> 00:33:19.819
when that scenario presents. You reminded me

00:33:19.819 –> 00:33:22.720
when you were talking, I was a history major

00:33:22.720 –> 00:33:25.359
in school before I ever thought about going into

00:33:25.359 –> 00:33:28.200
medicine. And so I’m always fascinated when I

00:33:28.200 –> 00:33:31.380
learn, or at least what I think I’m learning

00:33:31.380 –> 00:33:34.220
about the historical perspective. Tell me if

00:33:34.220 –> 00:33:38.319
I’m wrong, the story behind Protopic. And topical

00:33:38.319 –> 00:33:39.960
calcineurin inhibitors, not necessarily just

00:33:39.960 –> 00:33:42.880
Protopic. When they first came out, there was

00:33:42.880 –> 00:33:48.180
no “black box” warning on them. The sort of the

00:33:48.180 –> 00:33:51.299
gates were up in terms of how you could use these

00:33:51.299 –> 00:33:54.460
medicines. And they weren’t steroids. They did

00:33:54.460 –> 00:33:56.740
not have the side effects or the purported side

00:33:56.740 –> 00:33:59.779
effects as steroids might have. So people, as

00:33:59.779 –> 00:34:02.200
I understood it, were using them willy-nilly

00:34:02.200 –> 00:34:05.400
might be a way to say it. Hey, that’s a red rash

00:34:05.400 –> 00:34:07.839
that’s raised. It looks like eczema. Put some

00:34:07.839 –> 00:34:10.639
topical calcineurin inhibitor on that rash and.

00:34:10.800 –> 00:34:14.039
I’ll see you back in six months. And this is

00:34:14.039 –> 00:34:16.360
the part where I’m asking rather than stating

00:34:16.360 –> 00:34:19.340
historical fact. What I’ve been told is that

00:34:19.340 –> 00:34:23.860
where that “black box” warning came was that some

00:34:23.860 –> 00:34:26.639
patients were not responding, ultimately wound

00:34:26.639 –> 00:34:30.300
up probably seeing a dermatologist, getting a

00:34:30.300 –> 00:34:34.360
biopsy, only to find out, hey, what we just biopsied

00:34:34.360 –> 00:34:37.480
was a skin cancer, a lymphoma. called mycosis

00:34:37.480 –> 00:34:39.340
fungoides, or something that looks like that.

00:34:39.719 –> 00:34:42.320
And then, of course, the big decision was, geez,

00:34:42.480 –> 00:34:46.280
did the medicine cause your eczema to turn into

00:34:46.280 –> 00:34:50.340
a lymphoma, or was the original diagnosis, always

00:34:50.340 –> 00:34:54.519
lymphoma, just misdiagnosed as eczema? Do I have

00:34:54.519 –> 00:34:58.760
the story pretty accurate? Yeah, you do. And

00:34:58.760 –> 00:35:00.079
I guess, first of all, now I have to send you

00:35:00.079 –> 00:35:01.599
a “thank you” note from my brother, who’s a history

00:35:01.599 –> 00:35:03.820
professor at Rice, so respect for that background.

00:35:05.119 –> 00:35:09.679
But 100%. So these were the first non-steroidals

00:35:09.679 –> 00:35:11.420
to come out that actually worked, right? I mean,

00:35:11.440 –> 00:35:20.619
back in 2000, 2001, tacrolimus (Protopic), Pimecrolimus

00:35:20.619 –> 00:35:23.900
(Elidel) – “Willy” and “Nilly,” if you will – were the

00:35:23.900 –> 00:35:27.590
ones that came out, and they worked. And they

00:35:27.590 –> 00:35:30.769
were never studied in the United States in kids

00:35:30.769 –> 00:35:33.110
under two years of age or never approved in kids

00:35:33.110 –> 00:35:36.789
under two years of age. And yet, when our parents

00:35:36.789 –> 00:35:39.869
and providers most worried about topical steroid

00:35:39.869 –> 00:35:42.489
safety. kids under two years of age and so they

00:35:42.489 –> 00:35:45.550
were used like water because they finally there’s

00:35:45.550 –> 00:35:48.469
a non -steroid that worked and here we go and

00:35:48.469 –> 00:35:54.610
um that was seen by the fda that this off-label

00:35:54.610 –> 00:35:58.250
use in infants was was was happening um as we

00:35:58.250 –> 00:36:01.150
alluded a little bit earlier a very young two

00:36:01.150 –> 00:36:03.730
-month -old preemie from head to toe eczema you

00:36:03.730 –> 00:36:06.070
put enough on their skin head to toe twice a

00:36:06.070 –> 00:36:08.170
day for a while it they are going to absorb enough

00:36:08.170 –> 00:36:10.949
to matter. And so they were worried that there

00:36:10.949 –> 00:36:15.510
were going to be potential risks that were not

00:36:15.510 –> 00:36:18.710
studied that came from that off -label use. And

00:36:18.710 –> 00:36:21.650
so five years later, the FDA looked at this and

00:36:21.650 –> 00:36:24.230
affixed that “black box” warning. And some of that

00:36:24.230 –> 00:36:26.570
had to do with the potential of biopsy having

00:36:26.570 –> 00:36:31.250
shown mycosis fungoides. But as you say, mycosis

00:36:31.250 –> 00:36:33.570
fungoides, that… publication that i alluded

00:36:33.570 –> 00:36:35.030
to a moment ago that’s coming out that’s one

00:36:35.030 –> 00:36:37.030
of the first things we say that can look like

00:36:37.030 –> 00:36:40.530
eczema is mycosis fungoides and so was it that

00:36:40.530 –> 00:36:44.690
was it eczema all along don’t know um that that

00:36:44.690 –> 00:36:47.630
was that was really the issue so i 100% agree

00:36:47.630 –> 00:36:50.230
with that and to take that one step further the

00:36:50.230 –> 00:36:52.469
way that i will reassure parents is you know

00:36:52.469 –> 00:36:54.769
when those came out You know, tacrolimus, for

00:36:54.769 –> 00:36:58.969
instance, a 0 .03 % for kids up to 15, 0 .1 %

00:36:58.969 –> 00:37:02.449
for kids older than 15 and adults. Well, what

00:37:02.449 –> 00:37:05.250
was studied before they were approved, a 0 .3%.

00:37:05.559 –> 00:37:09.559
So an order of magnitude stronger than the weaker

00:37:09.559 –> 00:37:12.159
one that’s been approved for kids. And those

00:37:12.159 –> 00:37:14.500
studies didn’t even show significant absorption

00:37:14.500 –> 00:37:18.320
in the trials that made anyone worry in two -year

00:37:18.320 –> 00:37:21.219
-olds and older. But we’ve just got so much data

00:37:21.219 –> 00:37:22.940
and position papers from American Academy of

00:37:22.940 –> 00:37:25.960
Dermatology and allergists saying that that boxed

00:37:25.960 –> 00:37:29.480
warning was an overreach, which on the one hand,

00:37:29.480 –> 00:37:33.949
I appreciated because it did stop inappropriate,

00:37:34.090 –> 00:37:37.010
off -label, sort of uncontrolled use of these

00:37:37.010 –> 00:37:40.309
products. The flip side was you and I both have

00:37:40.309 –> 00:37:42.510
patients for whom they’re absolutely perfect,

00:37:42.590 –> 00:37:46.150
perfect complements to the topical steroid use,

00:37:46.250 –> 00:37:48.909
if not monotherapy, and yet parents are scared

00:37:48.909 –> 00:37:53.190
by that box warning. Oh, and if you don’t bring

00:37:53.190 –> 00:37:57.130
that warning up before mom reads it on the

00:37:57.130 –> 00:38:00.269
box from the pharmacist, you have lost that patient.

00:38:00.409 –> 00:38:03.030
I think more often than not, they’re done. “How

00:38:03.030 –> 00:38:05.429
come Dr. Krakowski didn’t tell me this could

00:38:05.429 –> 00:38:09.170
cause lymphoma?” Right. Yeah. So that’s a five

00:38:09.170 –> 00:38:12.469
to 10 minute discussion. And that adds up if

00:38:12.469 –> 00:38:14.170
you’re doing it six to eight times a day. And

00:38:14.170 –> 00:38:16.389
it’s just “in the trenches” pediatric dermatology.

00:38:17.690 –> 00:38:21.349
Exactly right. Rob, how do you use a referral

00:38:21.349 –> 00:38:24.530
to an allergist for these severe patients? Specifically,

00:38:25.869 –> 00:38:29.170
How do you partner with them? How do you maybe

00:38:29.170 –> 00:38:31.989
maintain the same messaging? And how do you use

00:38:31.989 –> 00:38:34.769
the objective test that they might ask for? Skin

00:38:34.769 –> 00:38:39.230
prick or, geez, IgE, RAS, blood testing. Do you,

00:38:39.309 –> 00:38:42.050
I guess, would be a good starting point. Yeah,

00:38:42.130 –> 00:38:44.010
talk about a five to ten minute discussion for

00:38:44.010 –> 00:38:46.969
the box warning with some urine inhibitors. There’s

00:38:46.969 –> 00:38:49.829
your one hour discussion with parents. I brought

00:38:49.829 –> 00:38:52.690
my 600-page allergy report. Would you like to

00:38:52.690 –> 00:38:57.000
read it? Oh my goodness. Yes. Well, I’ll tell

00:38:57.000 –> 00:38:58.940
you, I was super spoiled. One of my first stops

00:38:58.940 –> 00:39:00.559
along the way was at Boston Children’s where

00:39:00.559 –> 00:39:03.880
literally right next door was Dr. Linda Schneider,

00:39:03.920 –> 00:39:06.420
who is just, I’m sure you know, just a wonderful

00:39:06.420 –> 00:39:09.440
pediatric allergist at Boston Children’s. And

00:39:09.440 –> 00:39:12.280
I was just like, wow, why do people find this

00:39:12.280 –> 00:39:14.829
allergy dermatology? discussion is so challenging.

00:39:14.909 –> 00:39:17.010
You just go next door and talk to this brilliant

00:39:17.010 –> 00:39:19.789
woman and she distills it and then you see the

00:39:19.789 –> 00:39:23.090
patient together and it’s so easy. That didn’t

00:39:23.090 –> 00:39:28.769
turn out to be reality. So since I’ve sort of

00:39:28.769 –> 00:39:31.530
been in the weeds with this because it’s a tough

00:39:31.530 –> 00:39:34.579
question. Andrew, as you know, because kids with

00:39:34.579 –> 00:39:37.940
eczema are more likely to have food allergies.

00:39:38.019 –> 00:39:39.780
We’ll just stay there for now. Of course, there

00:39:39.780 –> 00:39:41.139
are environmental allergies. There’s contact

00:39:41.139 –> 00:39:42.719
allergies. There’s all sorts of things. But they’re

00:39:42.719 –> 00:39:44.739
more likely to have food allergies, for instance.

00:39:45.800 –> 00:39:47.440
Especially the severe ones is what we’re looking

00:39:47.440 –> 00:39:49.360
at. Exactly. Especially the severe ones. And

00:39:49.360 –> 00:39:53.610
the challenge is… That is true, but oftentimes

00:39:53.610 –> 00:39:56.289
they’re “co-passengers.” One doesn’t cause the

00:39:56.289 –> 00:39:58.909
other. And there’s not this food that’s hidden

00:39:58.909 –> 00:40:01.690
in the environment or the diet that the parents,

00:40:01.849 –> 00:40:04.570
you know, what is eczema for a parent? It is

00:40:04.570 –> 00:40:08.570
utter loss of control. It is watching their child

00:40:08.570 –> 00:40:12.030
be miserable, lose sleep, get infections every

00:40:12.030 –> 00:40:14.050
other day when they’re doing everything they

00:40:14.050 –> 00:40:16.530
can to prevent that. And it just keeps happening.

00:40:16.670 –> 00:40:19.960
And what can they control? Their diet. And they’ve

00:40:19.960 –> 00:40:21.780
got, oh, well, yeah, their food allergies are

00:40:21.780 –> 00:40:23.800
more common. This is what I control. Let’s restrict

00:40:23.800 –> 00:40:27.480
the diet. Let’s beat every allergy bush we can

00:40:27.480 –> 00:40:30.239
to see if that’s the problem. Sometimes it is,

00:40:30.300 –> 00:40:33.360
but more often than not, it’s not. And so that’s

00:40:33.360 –> 00:40:36.639
just a challenging thing to say, okay, let’s…

00:40:37.039 –> 00:40:39.639
And maybe this gets back to your sort of comment

00:40:39.639 –> 00:40:41.440
about if you don’t bring up the box warning,

00:40:41.559 –> 00:40:42.800
you’re going to be dismissed. And you should

00:40:42.800 –> 00:40:46.079
be by that patient. If a parent comes in with

00:40:46.079 –> 00:40:47.780
a child and they’re like, I think this is food

00:40:47.780 –> 00:40:50.860
allergies. And I’ve taken history. There’s not

00:40:50.860 –> 00:40:53.119
really a clear temporal link between any food

00:40:53.119 –> 00:40:55.820
exposure and a flare. There may be not even a

00:40:55.820 –> 00:40:58.579
very atopic family. Just this kid has eczema.

00:40:58.659 –> 00:41:02.119
So I’m not really thinking very much that allergies

00:41:02.119 –> 00:41:04.320
playing a big role there. But the parents are

00:41:04.320 –> 00:41:07.699
really invested in it. thing I’m gonna say is

00:41:07.699 –> 00:41:11.119
oh no that’s silly let’s forget about that I’m

00:41:11.119 –> 00:41:12.840
gonna say for the reasons I just said I actually

00:41:12.840 –> 00:41:14.539
don’t think that’s probably playing a big role

00:41:14.539 –> 00:41:16.800
here but that’s let’s set that aside for now

00:41:16.800 –> 00:41:19.239
let’s not forget about it let’s set that aside

00:41:19.239 –> 00:41:22.860
and do A, B, C, D for your skin and come back without

00:41:22.860 –> 00:41:26.219
changing your diet But doing all these good things

00:41:26.219 –> 00:41:29.579
for the skin. And it’s amazing how often kids

00:41:29.579 –> 00:41:32.119
will come back. And if the parents see that and

00:41:32.119 –> 00:41:33.820
know they haven’t changed the diet, that’s the

00:41:33.820 –> 00:41:36.260
best allergy test there is. Because the prick

00:41:36.260 –> 00:41:38.699
test, the RAS test, good tests, informative,

00:41:38.900 –> 00:41:41.320
can sometimes provide a roadmap. There are also,

00:41:41.380 –> 00:41:43.460
as you well know, a lot of false positives there.

00:41:43.880 –> 00:41:46.659
And then you’ve got this child who is tolerating,

00:41:46.659 –> 00:41:48.900
let’s just say, dairy. So you take your history.

00:41:49.000 –> 00:41:50.519
No, they don’t seem to react when you take dairy.

00:41:50.619 –> 00:41:52.719
But boy, I’ve heard dairy is a common allergy

00:41:52.719 –> 00:41:55.730
in less tests. You get a test. It says, oh, RAS

00:41:55.730 –> 00:41:57.550
test positive, Prick test positive for dairy.

00:41:57.829 –> 00:42:00.030
Child still has bad eczema. Well, let’s take

00:42:00.030 –> 00:42:02.130
the dairy out. Well, if you take the dairy out

00:42:02.130 –> 00:42:05.369
long enough, you can cause a dairy allergy. The

00:42:05.369 –> 00:42:08.349
gut needs to see that protein to continue to

00:42:08.349 –> 00:42:11.489
develop tolerance. And so testing is not always

00:42:11.489 –> 00:42:13.869
just information. There can be a sharp edge to

00:42:13.869 –> 00:42:17.969
that as well. Yeah, I totally agree with you

00:42:17.969 –> 00:42:21.809
on that. For me, patch testing, I don’t. I’m

00:42:21.809 –> 00:42:23.550
sure you guys do that at Seattle Children’s.

00:42:23.550 –> 00:42:26.570
We have a pretty robust patch testing program.

00:42:26.929 –> 00:42:31.269
And I do sometimes get surprised when I find

00:42:31.269 –> 00:42:33.510
something that wouldn’t normally be clinically

00:42:33.510 –> 00:42:35.670
relevant. But geez, it’s there. And you sometimes

00:42:35.670 –> 00:42:38.489
do eliminate that and get some improvement. But

00:42:38.489 –> 00:42:43.650
from an allergy perspective, we have basically

00:42:43.650 –> 00:42:47.909
stopped recommending. the RAS testing. I just

00:42:47.909 –> 00:42:50.809
don’t find that it’s that useful. If to your

00:42:50.809 –> 00:42:53.349
point about the false positives, unless actually

00:42:53.349 –> 00:42:56.869
I’ll take a step back. If, if you’re, if by RAS

00:42:56.869 –> 00:43:00.949
testing, you’re not allergic to your dog, then

00:43:00.949 –> 00:43:02.869
I can say, geez, Fido has nothing to do with

00:43:02.869 –> 00:43:04.570
this. Get that out of your head. You know, that

00:43:04.570 –> 00:43:07.909
to me is useful, but otherwise I a hundred percent

00:43:07.909 –> 00:43:12.090
agree with you that there is no greater test.

00:43:12.860 –> 00:43:15.539
For is your child truly allergic to something

00:43:15.539 –> 00:43:19.079
then? Or I should say, is your eczema being driven

00:43:19.079 –> 00:43:22.619
by an allergy to something? Then let’s treat

00:43:22.619 –> 00:43:24.900
this eczema and prove to you without you doing

00:43:24.900 –> 00:43:28.559
anything else that the eczema can get better.

00:43:28.719 –> 00:43:31.599
And man, when that happens, something magical,

00:43:31.699 –> 00:43:33.519
you can see it in the parents’ faces. Again,

00:43:33.619 –> 00:43:37.019
it’s usually moms. Just take a, they breathe

00:43:37.019 –> 00:43:39.559
a. sigh of deep, deep relief that they don’t

00:43:39.559 –> 00:43:41.940
have to change everything. And that guilt, right?

00:43:42.000 –> 00:43:44.320
The guilt of, geez, could breastfeeding be causing

00:43:44.320 –> 00:43:47.199
this? I can’t even imagine what that would feel

00:43:47.199 –> 00:43:52.320
like. And it’s exhausting. And they get that

00:43:52.320 –> 00:43:53.980
off their chest – literally and figuratively,

00:43:54.000 –> 00:43:58.579
I guess – but yeah, interesting. So we’re very

00:43:58.579 –> 00:44:00.659
similar in that regards to how we approach that.

00:44:01.559 –> 00:44:04.579
Shifting gears a little bit to talk about management.

00:44:06.000 –> 00:44:08.920
We’re going to get to systemic therapies. Any

00:44:08.920 –> 00:44:12.719
tips or tricks that you have for your approach

00:44:12.719 –> 00:44:17.800
to optimizing topical therapies? Do you do wet

00:44:17.800 –> 00:44:22.159
wraps? Are you using bleach baths? Are you doing

00:44:22.159 –> 00:44:24.179
anything else that we should be thinking about

00:44:24.179 –> 00:44:27.800
before we move into discussion around using truly

00:44:27.800 –> 00:44:31.219
a systemic therapy? Yeah, for sure. And I love

00:44:31.219 –> 00:44:33.659
the way that you sort of led into topical therapy

00:44:33.659 –> 00:44:37.880
by including baths and moisturizers, not just

00:44:37.880 –> 00:44:42.079
leaping to medicines because it is the foundation

00:44:42.079 –> 00:44:45.139
of care for eczema. And that includes even when

00:44:45.139 –> 00:44:48.360
we talk about systemic therapies, continuing

00:44:48.360 –> 00:44:51.239
to moisturize and hydrate skin is really important.

00:44:51.599 –> 00:44:54.619
And it’s another area we were just talking about,

00:44:54.619 –> 00:44:57.519
the confusion surrounding allergy and its role

00:44:57.519 –> 00:45:00.900
in atopic dermatitis. Well, parents come in completely

00:45:00.900 –> 00:45:04.280
flummoxed about the role of bathing and moisturization

00:45:04.280 –> 00:45:06.880
with regard to atopic dermatitis, specifically

00:45:06.880 –> 00:45:10.280
bathing in particular. You know, they’ve read

00:45:10.280 –> 00:45:12.780
or been told that by one person that bathing

00:45:12.780 –> 00:45:15.960
is good, you should bathe every day for their

00:45:15.960 –> 00:45:17.780
child with eczema. They may have seen an equally

00:45:17.780 –> 00:45:20.480
reputable source who said, oh my gosh, your child

00:45:20.480 –> 00:45:22.420
has eczema? You should bathe them as little as

00:45:22.420 –> 00:45:25.210
possible, once a week or less. And so the first

00:45:25.210 –> 00:45:27.409
thing I try to do is say that neither of your

00:45:27.409 –> 00:45:30.510
sources, whoever told you A or B, even though

00:45:30.510 –> 00:45:33.429
they’re diametrically opposing viewpoints, are

00:45:33.429 –> 00:45:36.110
necessarily wrong. Again, trying to not, you

00:45:36.110 –> 00:45:38.269
know, a patient comes to me or to you, a specialist.

00:45:39.099 –> 00:45:41.139
And we throw their pediatrician under the bus.

00:45:41.579 –> 00:45:43.500
We’re throwing ourselves under the bus. That’s

00:45:43.500 –> 00:45:46.219
just stupid because they have a trusted source

00:45:46.219 –> 00:45:48.539
who they will continue their relationship with.

00:45:48.679 –> 00:45:50.719
And so we have to embrace that and integrate

00:45:50.719 –> 00:45:53.239
ourselves into that. And so what I’ll say is

00:45:53.239 –> 00:45:55.179
that is not wrong. What they told you is not

00:45:55.179 –> 00:45:59.340
wrong. However, here is… Here’s the key part.

00:45:59.480 –> 00:46:01.980
And oftentimes you can point to a child, especially

00:46:01.980 –> 00:46:05.059
a severe infant, because oftentimes they’ll have

00:46:05.059 –> 00:46:07.579
their cheeks are red right around their chest

00:46:07.579 –> 00:46:10.159
where they drools. It’s all red and itchy, patchy

00:46:10.159 –> 00:46:12.920
everywhere. And sometimes now babies with eczema

00:46:12.920 –> 00:46:15.280
can get diaper rash too. But sometimes you take

00:46:15.280 –> 00:46:18.369
off the diaper and it’s pristine. Or you look

00:46:18.369 –> 00:46:20.909
under the axilla…pristine. And those places,

00:46:20.969 –> 00:46:22.710
I always tell the parents, you know, look at

00:46:22.710 –> 00:46:25.329
your child. Look what the skin likes. It likes

00:46:25.329 –> 00:46:29.730
moisture. Now, it may be more to do with the

00:46:29.730 –> 00:46:32.409
microbial flora in those areas that’s keeping

00:46:32.409 –> 00:46:35.130
it so pristine. I don’t know. But I will use

00:46:35.130 –> 00:46:37.869
that as a teaching point to say, however you

00:46:37.869 –> 00:46:42.619
accomplish hydration. The skin barrier with eczema

00:46:42.619 –> 00:46:46.900
is leaky. Water escapes. Bacteria and allergens

00:46:46.900 –> 00:46:49.460
get in. We need to help that barrier because

00:46:49.460 –> 00:46:52.460
it’s not as competent while they’re having active

00:46:52.460 –> 00:46:55.860
severe eczema. So how we incorporate a bath is

00:46:55.860 –> 00:47:00.269
you bathe and… If you’re in a bath long enough,

00:47:00.309 –> 00:47:02.590
your fingertips get wrinkly, whether you’re in

00:47:02.590 –> 00:47:06.070
a pool, a river, an ocean. If you’re in the water

00:47:06.070 –> 00:47:08.190
long enough, your fingertips get wrinkly because

00:47:08.190 –> 00:47:10.809
that’s very thick skin, and you can sort of see

00:47:10.809 –> 00:47:13.530
the hydration, but water is soaking in your whole

00:47:13.530 –> 00:47:15.769
body. You just see it on the palms and soles.

00:47:15.789 –> 00:47:18.369
Use that as a timer. If you’re in long enough

00:47:18.369 –> 00:47:21.519
for those fingertips to wrinkle, get out within

00:47:21.519 –> 00:47:23.659
reason. It doesn’t have to be so exact as that,

00:47:23.780 –> 00:47:26.659
but within reason, get out, pat dry, and more

00:47:26.659 –> 00:47:30.219
importantly, before they unwrinkle, moisturize.

00:47:30.460 –> 00:47:33.539
The so-called “soak and seal.” If you do that

00:47:33.539 –> 00:47:37.019
and the parents find that bathing and soaking

00:47:37.019 –> 00:47:40.420
and sealing once a day is best, wonderful. If

00:47:40.420 –> 00:47:42.880
they tell me, boy, I did that and my child seemed

00:47:42.880 –> 00:47:44.980
to do better when I bathe them once a week, soak

00:47:44.980 –> 00:47:47.699
and seal, but I moisturize every other day. Wonderful.

00:47:47.900 –> 00:47:52.280
I try not to be too dogmatic about how often

00:47:52.280 –> 00:47:54.260
they bathe. Because number one, it’s not easy

00:47:54.260 –> 00:47:57.699
necessarily. Life happens. And that’s another

00:47:57.699 –> 00:48:00.380
guilt trip saying, oh, you must bathe your child

00:48:00.380 –> 00:48:02.420
every day. And maybe it actually is not the best

00:48:02.420 –> 00:48:04.780
thing for that child. Eczema is nothing if not

00:48:04.780 –> 00:48:07.239
an individual disease. There are these bedrock

00:48:07.239 –> 00:48:10.099
principles we’re talking about. But then the

00:48:10.099 –> 00:48:12.420
parents are the experts in their child’s skin.

00:48:12.460 –> 00:48:14.780
And they use these principles to sort of cobble

00:48:14.780 –> 00:48:19.639
together an action plan. Yeah, I would agree

00:48:19.639 –> 00:48:23.960
with that completely. I have in my mind, if you

00:48:23.960 –> 00:48:27.940
can get a good moisturizer onto that kid two,

00:48:28.019 –> 00:48:30.480
three times a day, I mean, I might be even asking

00:48:30.480 –> 00:48:33.320
too much, but I don’t really care about the bathing

00:48:33.320 –> 00:48:35.460
principles. Although I think I’ve changed a little

00:48:35.460 –> 00:48:40.320
bit in the sense that I don’t know about Seattle,

00:48:40.500 –> 00:48:42.900
but Bethlehem, and there’s a lot of reasons for

00:48:42.900 –> 00:48:45.489
it. It’s a big wrestling community. We have a

00:48:45.489 –> 00:48:50.150
lot of Staph aureus here. And people have looked

00:48:50.150 –> 00:48:52.610
at it. It’s a little higher than the normal what

00:48:52.610 –> 00:48:57.309
you would expect. So for me, a lot of our patients

00:48:57.309 –> 00:49:00.889
are colonized at least. Some of them are super

00:49:00.889 –> 00:49:04.949
infected with Staph aureus. So for me, that mechanical

00:49:04.949 –> 00:49:08.190
act of just getting some of that load off the

00:49:08.190 –> 00:49:11.510
skin is useful. So I have found myself more than

00:49:11.510 –> 00:49:15.820
not recommending once a day, short, five minute,

00:49:15.920 –> 00:49:19.599
lukewarm, get out of there. And then very importantly,

00:49:19.699 –> 00:49:22.139
to your point, moisturize. You got to soak and

00:49:22.139 –> 00:49:25.219
seal. You got to get that moisturizer on. I don’t

00:49:25.219 –> 00:49:30.119
know. Does that jive with, am I okay doing that?

00:49:30.599 –> 00:49:36.079
Oh, 100%. So to now feel the space to be honest

00:49:36.079 –> 00:49:39.960
and open about my practice, I recommend bathing

00:49:39.960 –> 00:49:43.079
once a day, soak and smear. Didn’t want there

00:49:43.079 –> 00:49:44.579
all of a sudden to be technical difficulties

00:49:44.579 –> 00:49:47.440
and my mic was cut. So I wanted to make sure

00:49:47.440 –> 00:49:50.880
that that was coherent with your practice. But

00:49:50.880 –> 00:49:54.460
the point being is not one size fits all. But

00:49:54.460 –> 00:49:56.239
yes, that’s exactly what I do. And that’s one

00:49:56.239 –> 00:49:58.119
of the reasons I do it. And that also gets another

00:49:58.119 –> 00:50:02.440
maybe… place we may or may not align is the

00:50:02.440 –> 00:50:04.860
use of bleach baths um you alluded to them a

00:50:04.860 –> 00:50:08.340
bit ago and i do recommend them um as a potential

00:50:08.340 –> 00:50:13.599
adjunct um to treating and and the That raises

00:50:13.599 –> 00:50:15.340
so many questions with, you know, some of our

00:50:15.340 –> 00:50:17.460
parents have three PhDs. And so they’re asking,

00:50:17.500 –> 00:50:18.960
what’s the mechanism? How does that work? What

00:50:18.960 –> 00:50:21.280
happened? And, you know, the concentrations we

00:50:21.280 –> 00:50:24.480
use in bleach baths don’t even kill staff in

00:50:24.480 –> 00:50:27.639
the water. But what they do is they are a non

00:50:27.639 –> 00:50:30.559
-steroidal anti -inflammatory treatment, no matter

00:50:30.559 –> 00:50:32.960
how counterintuitive that sounds, by putting

00:50:32.960 –> 00:50:35.179
bleach in the bath. And so it matters how you

00:50:35.179 –> 00:50:37.079
do it. You know, for me, the formula is half

00:50:37.079 –> 00:50:40.199
a teaspoon per gallon. Take a regular bath. At

00:50:40.199 –> 00:50:42.800
the end, I have them rinse off. get out, pat

00:50:42.800 –> 00:50:45.599
dry, moisturize. I have them do it once to twice

00:50:45.599 –> 00:50:47.340
a week, but if they’re doing better on the days

00:50:47.340 –> 00:50:49.340
after the bleach bath than the days before, they

00:50:49.340 –> 00:50:52.179
can do it more often. And it just gets at that

00:50:52.179 –> 00:50:55.769
idea. You know, Bethlehem, we… absolutely

00:50:55.769 –> 00:50:57.949
have this Staph carriage issue that you alluded

00:50:57.949 –> 00:51:00.650
to there. And I’ll sort of describe for parents

00:51:00.650 –> 00:51:04.329
that Staph aureus is like gasoline on the fire

00:51:04.329 –> 00:51:07.250
of the eczema. It doesn’t cause it, but it certainly

00:51:07.250 –> 00:51:09.630
drives it along and then can get to a point where

00:51:09.630 –> 00:51:11.590
there’s a conflagration and you actually have

00:51:11.590 –> 00:51:13.409
oral antibiotics, you have an infection. But

00:51:13.409 –> 00:51:17.769
when it’s just just carriage, you need to address

00:51:17.769 –> 00:51:19.329
that as part of the treatment. And that’s one

00:51:19.329 –> 00:51:21.090
of the reasons that the bleach baths are so helpful.

00:51:21.610 –> 00:51:23.309
Yeah. And I think one of the things you said

00:51:23.309 –> 00:51:25.590
that’s most important to call out is the need

00:51:25.590 –> 00:51:27.909
to rinse off with fresh water after the bleach

00:51:27.909 –> 00:51:30.789
bath. I have I’ve had some patients not do that.

00:51:30.869 –> 00:51:34.289
And you get dry, probably drier than you would

00:51:34.289 –> 00:51:35.989
be without the bleach baths from the chlorine.

00:51:37.030 –> 00:51:40.110
Painfully, my two boys are swimmers and we’re

00:51:40.110 –> 00:51:42.309
in the middle of summer swim right now. And both

00:51:42.309 –> 00:51:45.889
of them are developing xerosis (“dryness”) from.

00:51:46.320 –> 00:51:49.300
being in the water. One of them showers right

00:51:49.300 –> 00:51:51.659
after he gets out of the pool, The other comes

00:51:51.659 –> 00:51:55.619
home about 15-20 minutes later and is supposed to

00:51:55.619 –> 00:51:58.480
shower. Most of the time he does but man even

00:51:58.480 –> 00:52:01.239
good moisturizers when you’re putting them on

00:52:01.239 –> 00:52:04.320
that sort of cracked dry skin they can sting

00:52:04.320 –> 00:52:06.800
and that’s been an issue for my boys so i can

00:52:06.800 –> 00:52:10.460
imagine what having moderate, severe, open, cracked

00:52:10.460 –> 00:52:12.820
eczema skin, some of those products that we’re

00:52:12.820 –> 00:52:14.579
asking our patients to use, especially like a

00:52:14.579 –> 00:52:17.039
steroid, topical steroid, where we know stinging

00:52:17.039 –> 00:52:19.519
is going to occur. It must really be an issue

00:52:19.519 –> 00:52:22.420
for them. So yeah, rinsing off as quickly as

00:52:22.420 –> 00:52:24.559
possible and then moisturizing as quickly as

00:52:24.559 –> 00:52:26.420
possible after the bleach bath, I find to be

00:52:26.420 –> 00:52:30.179
very helpful and to mitigate that. Agree. So

00:52:30.179 –> 00:52:33.920
how has your approach to systemic therapy for

00:52:33.920 –> 00:52:36.659
your severe atopic dermatitis patients changed

00:52:36.659 –> 00:52:41.440
in the last… five to 10 years. How’s that for

00:52:41.440 –> 00:52:45.179
a way? Changed a wee bit. Changed a wee bit.

00:52:45.519 –> 00:52:49.300
Well, I’ll just give you a sort of a very simple

00:52:49.300 –> 00:52:52.460
way to describe how much it’s changed. When we

00:52:52.460 –> 00:52:54.500
did our first atopic dermatitis guidelines for

00:52:54.500 –> 00:52:57.679
the AAD in 2004, we met for six hours in a hotel

00:52:57.679 –> 00:53:04.320
and we were done. in 2014 took a little longer

00:53:04.320 –> 00:53:08.440
still in 2014 so from 2000 when all we were just

00:53:08.440 –> 00:53:10.539
talking about the topical calcineurin inhibitors

00:53:10.539 –> 00:53:14.679
2000 2001 when they came out to 2017 there was

00:53:14.679 –> 00:53:18.480
not a single novel molecule for atopic dermatitis

00:53:18.480 –> 00:53:20.659
that came out there were me too topical steroids

00:53:20.659 –> 00:53:22.980
and things like that but not a single novel molecule

00:53:22.980 –> 00:53:28.260
in 2017 dupilumab (Dupixent) came out uh for adults

00:53:28.260 –> 00:53:31.059
it’s since been approved we’ve been one of the

00:53:31.260 –> 00:53:33.599
sites of the pediatric trials for all the age

00:53:33.599 –> 00:53:35.980
groups went down to 12 went down to six years

00:53:35.980 –> 00:53:39.760
now down to six months of age a biologic injectable

00:53:39.760 –> 00:53:41.900
medication depending on the age once a month

00:53:41.900 –> 00:53:45.760
or twice a month uh for moderate to severe atopic

00:53:45.760 –> 00:53:47.679
dermatitis the kind of kids we’re talking about

00:53:47.679 –> 00:53:51.039
patients we’re talking about and it’s 100% revolutionized

00:53:51.039 –> 00:53:55.159
my my treatment because prior to 2017 what was

00:53:55.159 –> 00:53:58.500
the only systemic medication approved for this

00:53:58.500 –> 00:54:02.320
patient population oral systemic steroids. So

00:54:02.320 –> 00:54:05.619
exactly what we don’t want to use if we can help

00:54:05.619 –> 00:54:07.840
it. So, and why is that? That’s actually worth,

00:54:07.880 –> 00:54:10.019
I was glad that you brought that up because I

00:54:10.019 –> 00:54:13.219
was going to be going to start with that one.

00:54:13.300 –> 00:54:16.460
So why, why don’t we like that? Yeah, it’s right.

00:54:16.599 –> 00:54:20.039
It’s seductively effective, isn’t it? Good word.

00:54:21.199 –> 00:54:26.860
It is just not a chronic intervention and atopic

00:54:26.860 –> 00:54:30.320
dermatitis is a chronic intervention. Systemic

00:54:30.320 –> 00:54:32.820
steroids chronically can have significant side

00:54:32.820 –> 00:54:36.960
effects, bony impacts, infection, on down the

00:54:36.960 –> 00:54:41.219
line. And I use the term seductive because we’ve

00:54:41.219 –> 00:54:42.980
already described these families who are losing

00:54:42.980 –> 00:54:45.780
sleep, getting infections, all sorts of things.

00:54:46.510 –> 00:54:49.550
a day or two of oral steroids. And my goodness,

00:54:49.690 –> 00:54:52.449
it’s like a different kid. They’re sleeping like

00:54:52.449 –> 00:54:55.789
a baby. They are not infected. They are looking

00:54:55.789 –> 00:54:58.769
like a million bucks, not itching. The problem

00:54:58.769 –> 00:55:01.670
is when that course ends, whether it’s five days

00:55:01.670 –> 00:55:04.610
later or three weeks later, it’s just going to

00:55:04.610 –> 00:55:07.030
come rolling right back. Sometimes so-called

00:55:07.030 –> 00:55:09.630
“rebound” – sometimes worse than it was before.

00:55:09.969 –> 00:55:13.650
And so there are times when I’ve got a kid who

00:55:13.650 –> 00:55:16.150
is so inflamed, head to toe, everything. stings

00:55:16.150 –> 00:55:19.369
just like you said so the things we need to use

00:55:19.369 –> 00:55:23.750
to recover uh are not there sometimes i will

00:55:23.750 –> 00:55:26.849
have to use the steroids briefly to calm them

00:55:26.849 –> 00:55:29.949
down so we can use the more sustainable therapies

00:55:29.949 –> 00:55:32.849
so i i will not say that i never use systemic

00:55:32.849 –> 00:55:37.079
steroids but but i try not to And prior to 2017,

00:55:37.440 –> 00:55:40.059
that was it. That’s all we had. We had non -steroidal

00:55:40.059 –> 00:55:42.500
options like cyclosporine and methotrexate, but,

00:55:42.559 –> 00:55:44.820
you know, those are pretty heavy-hitting medicines,

00:55:44.900 –> 00:55:47.760
and I still use them too sometimes. But since

00:55:47.760 –> 00:55:52.619
2017, we had for the first time an FDA -approved

00:55:52.619 –> 00:55:55.760
non -steroidal intervention, systemic intervention

00:55:55.760 –> 00:55:58.940
for atopic dermatitis. That was dupilumab, dupixin.

00:55:58.980 –> 00:56:03.480
Since then, there are other biologics, tralokinumab,

00:56:03.679 –> 00:56:07.280
lebrikizumab. nemolizumab – lots of “MABs” – all of

00:56:07.280 –> 00:56:10.760
these “monoclonal antibodies” (MABs) that treat

00:56:10.760 –> 00:56:14.059
eczema. There are small molecules, so -called

00:56:14.059 –> 00:56:19.260
JAK inhibitors approved. So those are oral once

00:56:19.260 –> 00:56:22.280
a day agents for moderate to severe atopic dermatitis.

00:56:22.360 –> 00:56:25.340
So a whole different landscape. And so, yeah,

00:56:25.400 –> 00:56:27.960
100 % different than I used to use five, 10 years

00:56:27.960 –> 00:56:32.500
ago. If I came to your clinic. tomorrow as a

00:56:32.500 –> 00:56:34.980
patient of yours, do you have sort of an a la

00:56:34.980 –> 00:56:38.500
carte? And let’s just assume I have severe, moderate

00:56:38.500 –> 00:56:41.079
to severe atopic dermatitis that has been recalcitrant

00:56:41.079 –> 00:56:42.960
to all the topical interventions we’ve mentioned.

00:56:43.519 –> 00:56:49.639
Do you have sort of a a la carte go -to in your

00:56:49.639 –> 00:56:51.820
mind of what you would start with and how you

00:56:51.820 –> 00:56:54.880
would work from there? Yeah, I guess first of

00:56:54.880 –> 00:56:57.840
all, if you came to my clinic tomorrow, I’d say,

00:56:57.880 –> 00:57:01.800
I’m sorry, Andrew, you’re way too old. I feel

00:57:01.800 –> 00:57:05.440
like I’m 16, Rob. I’d have to send you down the

00:57:05.440 –> 00:57:09.639
road. I’m so sorry. However, I take your point.

00:57:09.719 –> 00:57:13.099
If a patient came to my… My clinic, a pediatric

00:57:13.099 –> 00:57:16.719
patient, yes, indeed. By far, again, I’m a pediatric

00:57:16.719 –> 00:57:18.860
provider, so this doesn’t necessarily translate

00:57:18.860 –> 00:57:25.099
to the first -line approach to adult patients,

00:57:25.239 –> 00:57:30.699
but my first go -to is dupilumab. Why? It’s been

00:57:30.699 –> 00:57:32.480
around the longest, so we have the longest track

00:57:32.480 –> 00:57:35.179
record. It’s approved down to six months of age.

00:57:35.239 –> 00:57:37.139
None of the others are. All the other systemic

00:57:37.139 –> 00:57:39.019
medications, the youngest age of approval is

00:57:39.019 –> 00:57:42.699
12 years of age. One of the oral JAK inhibitors

00:57:42.699 –> 00:57:44.559
is approved down to two years of age in Europe,

00:57:44.679 –> 00:57:47.280
but not in the United States. So I’m comfortable

00:57:47.280 –> 00:57:50.139
using these things off -label other than dupilumab

00:57:50.139 –> 00:57:52.320
when I need to. But to answer your question,

00:57:52.400 –> 00:57:56.829
that is my first go -to. Don’t need to check

00:57:56.829 –> 00:57:59.650
blood tests to monitor it like we do some medications.

00:57:59.829 –> 00:58:02.010
So even though it’s an injection, which is never

00:58:02.010 –> 00:58:05.429
a wonderful thing to hear for a pediatric patient,

00:58:05.530 –> 00:58:07.610
that their treatment’s going to be a shot. It

00:58:07.610 –> 00:58:10.650
can be as little as once a month, as much as

00:58:10.650 –> 00:58:13.190
twice a month. So it’s not that frequent. We

00:58:13.190 –> 00:58:16.190
have ways of making it more tolerable. So that’s

00:58:16.190 –> 00:58:19.230
sort of where I start. But then absolutely have

00:58:19.230 –> 00:58:23.090
patients on all of those other medications. What

00:58:23.090 –> 00:58:25.349
are some of those specific? interventions that

00:58:25.349 –> 00:58:28.690
you mentioned or alluded to for the shots for

00:58:28.690 –> 00:58:30.429
giving the shots what’s uh what are some of your

00:58:30.429 –> 00:58:33.909
tricks yeah but in terms of systemic medications

00:58:33.909 –> 00:58:37.309
or oh just anything that makes the patient more

00:58:37.309 –> 00:58:39.949
at ease with having or giving themselves the

00:58:39.949 –> 00:58:44.349
injection oh gotcha yeah of course so um first

00:58:44.349 –> 00:58:46.750
of all i’ll sort of we’ll kind of go through

00:58:46.750 –> 00:58:48.449
sort of the mechanics of it so it’s something

00:58:48.449 –> 00:58:51.340
that’s done at home So kids don’t like shots,

00:58:51.460 –> 00:58:53.179
period, but they also don’t like going to the

00:58:53.179 –> 00:58:55.619
doctor and getting shot. So we can reassure that

00:58:55.619 –> 00:58:57.139
it’s something done at home. Of course, then

00:58:57.139 –> 00:58:58.960
the parents are the worried ones, not the kids,

00:58:59.099 –> 00:59:01.119
because they’re not always so thrilled about

00:59:01.119 –> 00:59:04.380
that idea. But we talk about some really important

00:59:04.380 –> 00:59:07.420
things to make it hurt less. Number one, the

00:59:07.420 –> 00:59:09.219
medicine’s got to be at room temperature, so

00:59:09.219 –> 00:59:11.320
you’ve got to let it warm up, number one. Number

00:59:11.320 –> 00:59:13.480
two, we always try to figure out a way so the

00:59:13.480 –> 00:59:15.880
child’s comfortable and feels like there’s some

00:59:15.880 –> 00:59:18.039
element of control, and a lot of times that’s

00:59:18.039 –> 00:59:22.449
a child hugging one parent if this family is

00:59:22.449 –> 00:59:25.030
able to have two people give the shot at the

00:59:25.030 –> 00:59:27.170
same time that’s a luxury not all families have

00:59:27.170 –> 00:59:31.409
but if they do one parent sort of or one one

00:59:31.409 –> 00:59:35.269
helper hold the child while the legs are sticking

00:59:35.269 –> 00:59:39.030
out on the other side and we can put ice for

00:59:39.030 –> 00:59:41.469
about five ten seconds before to cool off the

00:59:41.469 –> 00:59:45.289
surface and then give the injection you can also

00:59:46.670 –> 00:59:48.929
Use Emla cream, numbing cream, for about half

00:59:48.929 –> 00:59:52.190
an hour before. And then the ice. Those two things

00:59:52.190 –> 00:59:54.530
can be done together. And then finally, you can

00:59:54.530 –> 00:59:57.389
do all of those things. And then someone proximal

00:59:57.389 –> 01:00:00.110
to the shot. So if the shot’s being given, say,

01:00:00.170 –> 01:00:03.210
mid -thigh, a little higher up on that same thigh,

01:00:03.469 –> 01:00:06.309
you can sort of tickle or scratch or use a vibratory

01:00:06.309 –> 01:00:08.369
device. There’s something in pediatrics called

01:00:08.369 –> 01:00:10.849
a Buzzy Bee” that literally is just a vibratory

01:00:10.849 –> 01:00:13.309
device that you use to sort of stimulate that

01:00:13.309 –> 01:00:16.900
skin proximal to the shot. confuses the pain

01:00:16.900 –> 01:00:19.179
fibers such that it just doesn’t hurt as much.

01:00:19.320 –> 01:00:22.219
Yeah, that’s exactly what we do. I might add

01:00:22.219 –> 01:00:26.739
that I dole out lollipops like I’m a pro -diabetes

01:00:26.739 –> 01:00:29.860
physician in the clinic. But I find that that

01:00:29.860 –> 01:00:33.219
little burst of sucrose right before the shot

01:00:33.219 –> 01:00:38.320
is given is a good distractor. But yeah, everything

01:00:38.320 –> 01:00:41.099
that you just mentioned, I try to incorporate

01:00:41.099 –> 01:00:44.179
into giving the shots. And I find that The vast

01:00:44.179 –> 01:00:47.300
majority of patients are happier being able to

01:00:47.300 –> 01:00:49.559
do that at home without coming in to see us,

01:00:49.659 –> 01:00:52.360
disrupting their lives. And then when you add

01:00:52.360 –> 01:00:54.920
to that the fact that the medicine works, it’s

01:00:54.920 –> 01:00:57.900
a real, I mean, it’s as close to a miracle as

01:00:57.900 –> 01:01:02.599
probably I’ve seen since Hemangeol for hemangiomas,

01:01:02.659 –> 01:01:05.039
which is the first real game changer that I’ve

01:01:05.039 –> 01:01:07.000
ever witnessed in medicine. So that’s kind of

01:01:07.000 –> 01:01:09.969
cool. The funny thing about Dupixent is – and

01:01:09.969 –> 01:01:12.130
I don’t know if it was hubris or because I was

01:01:12.130 –> 01:01:16.949
a scaredy cat – but I would say it took it really

01:01:16.949 –> 01:01:22.329
two years for me before I jumped on the bandwagon,

01:01:22.369 –> 01:01:25.070
you know, to use it. I just, I didn’t like the

01:01:25.070 –> 01:01:27.429
idea that it was an injection. And I just didn’t,

01:01:27.429 –> 01:01:30.889
I couldn’t get past the idea that, that a, my

01:01:30.889 –> 01:01:35.199
topical regimen couldn’t do it. That was probably

01:01:35.199 –> 01:01:37.920
the hubris part of it. And then, geez, what is

01:01:37.920 –> 01:01:40.599
this systemic medicine going to do? Is it going

01:01:40.599 –> 01:01:43.260
to cause these people to grow flippers or horns?

01:01:43.420 –> 01:01:49.199
And to your point, 18, 12, 6, 6 months. Geez,

01:01:49.300 –> 01:01:53.559
okay, no labs necessary. And people are walking

01:01:53.559 –> 01:01:56.900
into clinic that I saw just a couple months ago

01:01:56.900 –> 01:02:01.199
with severe disease. They’re now clear. You know,

01:02:01.219 –> 01:02:03.320
it’s amazing. And I have to give I have to say

01:02:03.320 –> 01:02:05.460
I have to give my private practice physicians

01:02:05.460 –> 01:02:11.300
a big hurrah on that one, because I think they

01:02:11.300 –> 01:02:13.639
might be a little faster to go to those newer

01:02:13.639 –> 01:02:15.659
medicines because the patients are seeing them

01:02:15.659 –> 01:02:18.599
on the commercials, which we can argue are not

01:02:18.599 –> 01:02:21.679
really helpful. But for in this case, they might

01:02:21.679 –> 01:02:25.280
be. And then because those adults were getting.

01:02:26.379 –> 01:02:29.400
Dupixent faster, sort of a trickle down. I would

01:02:29.400 –> 01:02:31.699
hear about it and go, geez, I, maybe I need to

01:02:31.699 –> 01:02:34.260
open my mind up to be a little bit more receptive

01:02:34.260 –> 01:02:37.199
to using a systemic medicine like that. And geez,

01:02:37.260 –> 01:02:40.739
that was five years ago. And now it’s to, to

01:02:40.739 –> 01:02:43.360
your point, it’s our, it’s our go -to for when,

01:02:43.420 –> 01:02:45.880
when everything else fails and you need a systemic

01:02:45.880 –> 01:02:49.280
therapy. It’s pretty amazing. Yeah, I completely

01:02:49.280 –> 01:02:51.800
agree. One thing I’ve always been interested

01:02:51.800 –> 01:02:54.159
in, and I haven’t really found anybody who does

01:02:54.159 –> 01:02:57.719
this yet. But to me, mechanistically, it seems

01:02:57.719 –> 01:03:01.260
like it works, would be if you had a patient,

01:03:01.300 –> 01:03:04.539
especially one with severe itch, who came in.

01:03:04.980 –> 01:03:09.039
And from your experience, how long do you give

01:03:09.039 –> 01:03:12.480
Dupixent before you start to expect it to work?

01:03:12.800 –> 01:03:15.559
Is there a number that you can kind of throw

01:03:15.559 –> 01:03:19.110
out? Yeah, I’ll usually tell parents that, you

01:03:19.110 –> 01:03:21.710
know, two, three weeks they will start to see

01:03:21.710 –> 01:03:24.309
some improvement. But if you look at sort of

01:03:24.309 –> 01:03:26.630
the curves in the studies, it’s a good two, three

01:03:26.630 –> 01:03:28.869
months before they start to plateau out at their

01:03:28.869 –> 01:03:32.719
peak effect. But I’ve had kids, and I think this

01:03:32.719 –> 01:03:35.639
may also be a bit of the psychology of it, because

01:03:35.639 –> 01:03:37.920
they come back and it has worked. And they’re

01:03:37.920 –> 01:03:40.860
like, the first shot, it worked after two or

01:03:40.860 –> 01:03:43.599
three days. And maybe it did. But I think it’s

01:03:43.599 –> 01:03:47.079
also, finally, something has worked. And so the

01:03:47.079 –> 01:03:51.360
mind sort of might change the time stamp a little

01:03:51.360 –> 01:03:54.219
bit. But it’s usually, you know, two weeks in

01:03:54.219 –> 01:03:56.539
there, they’re like, okay, I’m starting to feel

01:03:56.539 –> 01:03:58.719
it. I’m itching less and my skin’s less red.

01:03:59.019 –> 01:04:01.619
Yeah, agreed. And so one of the things I always

01:04:01.619 –> 01:04:04.320
thought was that, so sort of, okay, Dupixent

01:04:04.320 –> 01:04:07.260
with its safety profile and lack of blood work

01:04:07.260 –> 01:04:12.219
being not necessary to do blood work. Have you

01:04:12.219 –> 01:04:15.480
ever used a JAK inhibitor to “bridge” them onto

01:04:15.480 –> 01:04:17.599
Dupixent? And that’s just something I haven’t

01:04:17.599 –> 01:04:20.260
seen anybody do, but it makes sense because as

01:04:20.260 –> 01:04:23.500
I understand it, those JAKs are faster acting,

01:04:23.659 –> 01:04:26.420
a little bit better maybe for itch specifically.

01:04:26.840 –> 01:04:30.550
And could you get them? two three months bridged

01:04:30.550 –> 01:04:32.610
on to do pixen and then have the pixen carry

01:04:32.610 –> 01:04:35.909
the the rest of the way yeah absolutely i mean

01:04:35.909 –> 01:04:37.670
we used to do that with cyclosporine, right? we

01:04:37.670 –> 01:04:40.309
did it and it did work and it worked quicker than

01:04:40.309 –> 01:04:42.989
methotrexate, six, seven weeks, eight weeks.

01:04:43.110 –> 01:04:47.389
So we used to use cyclosporine to bridge patients

01:04:47.389 –> 01:04:50.050
to a more sustainable therapy, still do sometimes.

01:04:50.829 –> 01:04:54.929
And the theory behind that absolutely is right

01:04:54.929 –> 01:04:57.190
with JAK inhibitors. JAK inhibitors, I have had

01:04:57.190 –> 01:05:01.110
kids say literally a day or two, I’m itching

01:05:01.110 –> 01:05:04.300
less. It’s remarkable. The reason I don’t is

01:05:04.300 –> 01:05:07.300
because the folks in my office who work on prior

01:05:07.300 –> 01:05:12.980
authorizations might fire me. So one new medicine

01:05:12.980 –> 01:05:16.599
at a time for my crowd. Yeah, that’s the practical

01:05:16.599 –> 01:05:19.000
realities of not being able to do everything

01:05:19.000 –> 01:05:22.739
we necessarily want to do for the patients. So

01:05:22.739 –> 01:05:25.119
when Dupixent is not working in those rare cases

01:05:25.119 –> 01:05:28.639
when it doesn’t, how do you broach that with

01:05:28.639 –> 01:05:31.380
the patient? Where kind of do you go after that?

01:05:32.569 –> 01:05:35.130
Yeah, there’s some interesting sort of discussions

01:05:35.130 –> 01:05:37.869
on both ends of this spectrum. So the kids in

01:05:37.869 –> 01:05:39.769
the question you asked, the ones who don’t work,

01:05:39.929 –> 01:05:43.030
where do we go? And then the kids for whom it

01:05:43.030 –> 01:05:45.309
does work, what’s the end point? So that’s another

01:05:45.309 –> 01:05:49.360
really sort of… unclear um discussion but with

01:05:49.360 –> 01:05:51.599
regard to the question you asked i’ll usually

01:05:51.599 –> 01:05:54.599
say let’s give it a good three months um exactly

01:05:54.599 –> 01:05:56.260
for the reasons we talked about it that’s sort

01:05:56.260 –> 01:05:57.920
of when the curve starts to peak and if you’re

01:05:57.920 –> 01:06:00.699
just seeing nothing then like we talked about

01:06:00.699 –> 01:06:03.699
before step back why um it works for most why

01:06:03.699 –> 01:06:07.860
not this kid um and are they using it is there

01:06:07.860 –> 01:06:09.900
another diagnosis do we need to think about all

01:06:09.900 –> 01:06:13.980
those things great do that but let’s say We got

01:06:13.980 –> 01:06:15.780
the right diagnosis. They’re using it appropriately.

01:06:15.800 –> 01:06:17.579
It just isn’t the right medicine. What do we

01:06:17.579 –> 01:06:20.780
do? That’s when, for me, the next step is typically

01:06:20.780 –> 01:06:25.139
a JAK inhibitor. There are other, so getting

01:06:25.139 –> 01:06:27.880
back to your word mechanistically, so Dupixent

01:06:27.880 –> 01:06:33.860
works IL -4, IL -13. There are two new agents,

01:06:34.119 –> 01:06:36.559
Tralokinumab, Lebrikizumab, which are IL -13

01:06:36.559 –> 01:06:40.610
agents. I haven’t necessarily… looked in that

01:06:40.610 –> 01:06:42.789
direction because the mechanisms are similar.

01:06:43.210 –> 01:06:46.090
That isn’t necessarily proven that they wouldn’t

01:06:46.090 –> 01:06:48.610
respond, but I would generally think of either

01:06:48.610 –> 01:06:51.869
Nemolizumab, which is anti IL-31, a different mechanism,

01:06:51.989 –> 01:06:54.469
or one of the JAK inhibitors, which is a very

01:06:54.469 –> 01:06:56.829
different mechanism. Are you finding that you

01:06:56.829 –> 01:06:59.690
can get those accepted by insurance companies?

01:06:59.809 –> 01:07:02.010
I’m striking out most of the time with those.

01:07:02.130 –> 01:07:04.489
It’s a struggle for sure. They have to be 12

01:07:04.489 –> 01:07:08.739
or older. strikes a lot of my kids who are younger

01:07:08.739 –> 01:07:12.159
than 12 because off -label almost never am I

01:07:12.159 –> 01:07:17.400
able to. But I do have a number of kids older

01:07:17.400 –> 01:07:21.380
than 12 on mostly JAK inhibitors because the

01:07:21.380 –> 01:07:24.500
others are newer, but a few kids on Lebrikizumab

01:07:24.500 –> 01:07:28.840
and Tralokinumab and a few kids on Nemo. And

01:07:28.840 –> 01:07:33.460
either concurrently or separate from, what role

01:07:33.460 –> 01:07:36.699
do you… I don’t know if you know this living

01:07:36.699 –> 01:07:39.460
in Seattle, but there is a thing called the Sun.

01:07:39.599 –> 01:07:41.219
Now, we haven’t seen it much in Pennsylvania

01:07:41.219 –> 01:07:42.719
the last four weeks. How do you find that place?

01:07:43.139 –> 01:07:45.440
Yeah, yeah. You got to look up, but it’s there.

01:07:45.860 –> 01:07:49.760
And so when you don’t have access to 10 minutes

01:07:49.760 –> 01:07:52.260
a day of sun, sometimes we’ll use phototherapy.

01:07:53.559 –> 01:07:57.659
Wow. Yeah, I know. Do you even use phototherapy

01:07:57.659 –> 01:08:01.519
much these days? I do. I mean, we do a lot of

01:08:01.519 –> 01:08:05.519
it, actually. Not a lot. The challenge for us

01:08:05.519 –> 01:08:07.679
is we don’t have a phototherapy unit at our hospital,

01:08:07.780 –> 01:08:11.300
so we have to send them elsewhere. Now the University

01:08:11.300 –> 01:08:12.860
of Washington is right here. Our adult colleagues

01:08:12.860 –> 01:08:16.760
are right there, and they will treat kids to

01:08:16.760 –> 01:08:19.840
a certain age, and it’s sort of variable, but

01:08:19.840 –> 01:08:23.899
definitely not younger than six. And so we don’t

01:08:23.899 –> 01:08:25.819
use it a lot. My challenges with phototherapy

01:08:25.819 –> 01:08:31.399
are both logistical, insurance approval. The

01:08:31.399 –> 01:08:34.260
frequency of the need having to go in so often

01:08:34.260 –> 01:08:36.760
is a real logistical barrier for a lot of parents.

01:08:37.239 –> 01:08:39.359
And then a lot of times it’s a matter of the

01:08:39.359 –> 01:08:41.420
kids I most, most want to treat are those super

01:08:41.420 –> 01:08:43.939
inflamed kids. And oftentimes I have to kind

01:08:43.939 –> 01:08:45.880
of calm them down before phototherapy can kind

01:08:45.880 –> 01:08:48.300
of be, like we said, bridge them to the phototherapy.

01:08:48.420 –> 01:08:51.039
But I do and I have and I will, just not often.

01:08:51.439 –> 01:08:55.079
Do you ever use a medicine like Dupixent in combination

01:08:55.079 –> 01:08:58.359
with phototherapy or is that taboo? Yeah. No,

01:08:58.439 –> 01:09:00.439
no. I absolutely could do that. And I’ve used

01:09:00.439 –> 01:09:03.060
Dupixan in combination with methotrexate and

01:09:03.060 –> 01:09:07.239
other systemics. So I have done that. Yes. Yeah.

01:09:07.279 –> 01:09:10.979
Yeah. We use phototherapy oftentimes with the

01:09:10.979 –> 01:09:12.880
other systemics and usually with good effect.

01:09:12.960 –> 01:09:15.739
One thing to your point about the just practical

01:09:15.739 –> 01:09:17.640
nature of not coming in two to three times a

01:09:17.640 –> 01:09:20.399
week for… It’s only a couple of minutes, but

01:09:20.399 –> 01:09:23.119
it’s still just a nuisance. We’ve been very lucky.

01:09:23.180 –> 01:09:25.079
And I don’t know, maybe the insurance companies

01:09:25.079 –> 01:09:27.460
did the math and they just figured out it’s cheaper.

01:09:27.600 –> 01:09:32.300
But we’ve been very good at getting at -home

01:09:32.300 –> 01:09:35.300
units approved for our patients in this area,

01:09:35.340 –> 01:09:37.680
way more than any other place I’ve ever lived

01:09:37.680 –> 01:09:39.659
or worked. I don’t know if that’s a thing out

01:09:39.659 –> 01:09:42.859
in Seattle, but they’ve been, you know, for $6

01:09:42.859 –> 01:09:45.619
,000, you can… basically get a pretty decent

01:09:45.619 –> 01:09:47.180
at -home therapy of course you have to have a

01:09:47.180 –> 01:09:48.840
place to put it and it’s usually in the living

01:09:48.840 –> 01:09:52.180
room for for the family but um that’s that’s

01:09:52.180 –> 01:09:54.039
really done wonders for for some of these kids

01:09:54.039 –> 01:09:57.479
who need it yeah and i think you’re right i have

01:09:57.479 –> 01:09:59.819
a handful of kids with home units for sure and

01:09:59.819 –> 01:10:01.439
i think it is i can’t remember that study was

01:10:01.439 –> 01:10:03.600
like after three months you’re like paying it’s

01:10:03.600 –> 01:10:05.699
paid for itself the home unit so i think insurance

01:10:05.699 –> 01:10:09.119
companies see that yeah what do you think dr

01:10:09.119 –> 01:10:11.600
sidberry is on the horizon next couple years

01:10:11.600 –> 01:10:15.109
what are we going to see Oh, boy. There’s the

01:10:15.109 –> 01:10:17.189
National Eczema Association, which, as you know,

01:10:17.210 –> 01:10:20.050
is a wonderful advocacy group for patients with

01:10:20.050 –> 01:10:22.550
eczema, families with eczema. I’d highly recommend

01:10:22.550 –> 01:10:24.649
anyone listening to your program who’s not visited.

01:10:24.789 –> 01:10:27.489
I think it’s nationaleczema.org or something

01:10:27.489 –> 01:10:29.689
like that, but just Google “National Eczema Association.”

01:10:29.869 –> 01:10:33.109
You’ll find it. It has a page, a research page,

01:10:33.270 –> 01:10:37.319
and it lists all of the agents that are at

01:10:37.319 –> 01:10:39.840
certain stages of approval. So clinical trials,

01:10:39.859 –> 01:10:41.479
right? You got phase one, phase two, phase three,

01:10:41.520 –> 01:10:44.760
all of the things that are phase three or beyond.

01:10:44.899 –> 01:10:47.590
So that’s… that’s getting close to being a

01:10:47.590 –> 01:10:49.909
medicine that the FDA can look at and approve

01:10:49.909 –> 01:10:53.270
or not approve. And it is ridiculous. They’re

01:10:53.270 –> 01:10:56.949
like double -digit injectables, double -digit

01:10:56.949 –> 01:11:01.390
orals, double -digit topicals coming down the

01:11:01.390 –> 01:11:05.430
road. So I think additional MABS, as we’ve talked

01:11:05.430 –> 01:11:08.770
about, will be on the way. Probably additional

01:11:08.770 –> 01:11:11.909
JAK inhibitors. Some therapies that are sort

01:11:11.909 –> 01:11:13.989
of looking through a little bit different lens,

01:11:14.109 –> 01:11:16.930
maybe going back to the microbiome, some interesting

01:11:16.930 –> 01:11:19.569
topical and systemic therapies trying to address

01:11:19.569 –> 01:11:22.729
the cutaneous microbiome and its role that we’ve

01:11:22.729 –> 01:11:26.850
sort of alluded to in sustaining and triggering

01:11:26.850 –> 01:11:29.369
atopic dermatitis. So I think that’s probably

01:11:29.369 –> 01:11:32.670
where we’re headed. Also, with all these medicines

01:11:32.670 –> 01:11:34.449
we already have, including the ones that are

01:11:34.449 –> 01:11:37.229
to come, sort of personalized medicine. That’s

01:11:37.229 –> 01:11:41.869
sort of the vanguard, where we’re headed. perhaps

01:11:41.869 –> 01:11:44.449
seeing the genetics of a patient and then matching

01:11:44.449 –> 01:11:47.729
that to a certain medication if those studies

01:11:47.729 –> 01:11:50.949
come out and so direct us. Or Emma Gutman, MD in

01:11:50.949 –> 01:11:54.510
New York has done wonderful studies sort of characterizing

01:11:54.510 –> 01:11:57.489
the so -called inflammatory signature of eczema.

01:11:57.649 –> 01:12:00.010
And this patient with chronic eczema has more

01:12:00.010 –> 01:12:03.590
of that cytokine or that cytokine. And boy, let’s

01:12:03.590 –> 01:12:06.369
not try that IL -31 because there wasn’t much

01:12:06.369 –> 01:12:09.630
of that in that patient’s biopsy. Let’s try the

01:12:09.630 –> 01:12:11.619
other one. So things like… that i think are

01:12:11.619 –> 01:12:14.380
where we’re headed yes i i think they’re doing

01:12:14.380 –> 01:12:16.920
something similar for psoriasis out of Yale i

01:12:16.920 –> 01:12:20.920
saw and um geez i maybe i’m speaking for both

01:12:20.920 –> 01:12:24.840
of us i will not be sad uh the day that eczema

01:12:25.180 –> 01:12:27.659
gets cured. It would be a wonderful thing for

01:12:27.659 –> 01:12:30.460
everybody involved. Hopefully, we’ll see that

01:12:30.460 –> 01:12:33.300
in my lifetime as a practicing pediatric dermatologist.

01:12:33.460 –> 01:12:37.340
But certainly, it’s better to have eczema now

01:12:37.340 –> 01:12:41.039
in 2025 than it was, as we talked about, just

01:12:41.039 –> 01:12:43.520
five to 10 years ago. What a difference that

01:12:43.520 –> 01:12:46.920
short amount of time relative to our careers

01:12:46.920 –> 01:12:52.149
really leads to. So anyway. Great speaking with

01:12:52.149 –> 01:12:54.210
you, Dr. Robert Sidbury, Chief of Pediatric

01:12:54.210 –> 01:12:56.430
Dermatology at Seattle Children’s Hospital. Really

01:12:56.430 –> 01:12:58.689
do appreciate the time. It’s just an amazing

01:12:58.689 –> 01:13:02.430
resource to have you here and speaking to us

01:13:02.430 –> 01:13:04.510
and our audience. Thank you so much for taking

01:13:04.510 –> 01:13:06.789
the time. It’s a pleasure. Thanks for having

01:13:06.789 –> 01:13:12.109
me. Thanks for tuning in to this episode of the

01:13:12.109 –> 01:13:14.189
Don’t Be Rash Pediatric Dermatology Podcast.

01:13:14.779 –> 01:13:17.079
I’m your host, Dr. Andrew Krakowski. Don’t forget

01:13:17.079 –> 01:13:19.279
to subscribe to our show on your favorite podcast

01:13:19.279 –> 01:13:23.180
platform and check out don’tberash .org for more

01:13:23.180 –> 01:13:25.560
information. A special thank you to our nonprofit

01:13:25.560 –> 01:13:28.319
sponsor, the St. Luke’s University Health Network

01:13:28.319 –> 01:13:30.939
for making this episode possible. Until next

01:13:30.939 –> 01:13:33.899
time, remember, keep calm and don’t be rash.