PracticeUpdate Dermatology February 2019

TOP STORIES 2018 7

Hope on the Horizon for ChildrenWith Severe Atopic Dermatitis By Sarah L. Chamlin MD D upilumab received FDA approval for adults with atopic dermatitis (AD) in March of 2017, and approval for children with asthma 12 years and older was announced in October of 2018. FDA approval, published evidence of effi- cacy, and clinical experience for adult patients with atopic dermatitis strongly supports use of dupilumab. 1 In addition, this recent approval for a pediatric indication bodes well for children with AD, and phase III trials are underway for children with moderate to severe atopic dermatitis ages 6 months to 18 years of age. Unfortunately, due to insurance limitations and previous lack of a pediatric indication, few practi- tioners have experience using dupilumab off-label in children with AD. This private-practice group reported use in 6 children with severe AD with a mean age of 10.8 years. 2 All patients responded well, and 3 were almost clear (IGA of 1). This case series is a practical and real-world use of this drug in pediatric patients. The authors used a mean loading dose of 11.4 mg/kg and a mean biweekly dose of 5.7 mg/kg. Significant conjunc- tivitis was not reported in these patients, and the average duration of therapy was 8.5 months. Of these 6 patients, 5 had failed other systemic ther- apy, offering hope even for recalcitrant patients. Although the authors did not provide insight on how they were able to obtain insurance author- ization, this will be a significant hurdle to using dupilumab until FDA approval occurs. A labeled indication is likely many years away, and I hope to, very soon, partner with my allergy colleagues to gain experience using this for my patients with asthma and severe atopic dermatitis, the “kill two birds with one stone” approach. References 1. Seger EW, Wechter T, Strowd L, Feldman SR. Relative efficacy of systemic treatments for atopic dermatitis. J Am Acad Dermatol 2018 Oct 5. doi: 10.1016/j. jaad.2018.09.053. [Epub ahead of print.] 2. Treister AD, Lio PA. Long-term off-label dupilumab in pediatric atopic dermatitis: a case series. Pediatr Dermatol 2018 Oct 18. doi: 10.1111/pde.13697. [Epub ahead of print.] www.practiceupdate.com/c/76156

that has not been previously reported. Our commentary highlights some tips to recognize and prevent this. The second article in this realm, entitled, " Effectiveness of Low Doses of Hyaluronidase to Remove Hyaluronic Acid Filler Nodules ," was published in JAMA Dermatology this year. 3 The study evaluated the use of hyaluronidase for dissolving excess or improperly placed hyaluronic gels. Because hyaluronic acid gel injections are the most common filler injections globally, it is important to know the art and science of managing their complications and occasional unwanted outcomes. The authors share their findings regarding the concen- tration-dependent effect of hyaluronidase in dissolving unwanted hyaluronic acid filler. The accompanying commentary also addresses the more serious complication of impending vascular necrosis from intravascular injection of hyaluronic acid and the need for more concentration and large-volume use of hyaluronidase to manage those situations. A big shout out to my colleagues and mentors, Dr. Bob Brodell and Dr. Eliot Mostow, for allowing me to be part of this “comprehensive virtual journal club.” Also, a big thanks to our editorial board and our screeners and section edi- tors who do such a great job covering such a breadth of the most impactful findings in the dermatology literature and making them accessible to myself and our colleagues. I always look forward to our calls to discuss the literature and the impact on our specialty. Also, a big thanks to PracticeUpdate and the entire Elsevier team, who make the process so smooth and so much fun. References 1. Dayan SH, Bacos JT, Gandhi ND, et al. Assessment of the impact of perioral rejuvenation with hyaluronic acid filler on projected first impressions and mood perceptions. Dermatol Surg 2018 Jul 27. doi: 10.1097/DSS.0000000000001613. [Epub ahead of print.] 2. McKay C, Price C, Pruett L. Vascular injury after deoxycholic acid injection. Dermatol Surg 2018 May 9. doi: 10.1097/DSS.0000000000001550. [Epub ahead of print.] 3. Alam M, Hughart R, Geisler A, et al. Effectiveness of low doses of hyaluronidase to remove hyaluronic acid filler nodules: a randomized clinical trial. JAMA Dermatol 2018;154(7):765-772. www.practiceupdate.com/c/76155 " We find that both dermatologists and patients greatly underestimate the impact of disproportionate aging of the lower face on the overall appearance and impression of age from an observer’s perspective. "

VOL. 3 • NO. 1 • 2019