Pediatric Dermatology

Dr. Lawrence F. Eichenfield, Chief of Pediatric and Adolescent Dermatology at Rady Children's Hospital, San Diego, and Professor of Pediatrics and Medicine at University of California, San Diego, explains the current concerns of dermatology and his hopes for the future.

EHM. How does your pediatric dermatology department function at Rady Children’s Hospital, and what areas of research do you cover in the division?
LE. We have a large subspecialty practice and research unit dedicated to pediatric dermatology. The clinical trials unit has three RNs, two research fellows, fulltime administrative staff and phlebotomy. This group is involved in a broad set of clinical research projects, including atopic dermatitis, psoriasis, acne and cutaneous infections. We also have great interest in vascular lesions and hemangiomas, with staff doing basic and translational research as well as clinical research and work in procedural dermatology, including laser surgery in children.

EHM. How do the dermatological concerns and needs vary for the three tiers of pediatrics, and what would you say is really the most prevalent concern for each if you had to break it down?
LE. Probably the most common concerns for neonates and young children relate initially to birthmarks, such as hemangiomas, port wine stains, congenital moles and other congenital lesions. There are many conditions that present in the neonatal period which cause great familial and physician concern. After infancy, we see other dermatologic conditions that become quite prevalent. At six months of age and older, atopic dermatitis is somewhat common, with a 15-20 percent prevalence in the first few years of life.

Closer to school ages, children can have inflammatory diseases which include atopic dermatitis, other eczemas and, to a lesser degree, psoriasis. Cutaneous infections become more common, which include warts (human papillomavirus), molluscum contagiosum and bacterial infections such as impetigo.

In later childhood and adolescence, acne becomes incredibly common, with a 90 percent or higher prevalence during the teenage life. From childhood through adolescence, moles are an increasing concern. Other than those present at birth, known as congentital moles, acquired moles approach almost a 100 percent prevalence by adolescence. Not all moles are necessarily worrisome, but this does create a fairly large amount of dermatologic concerns in this population.

EHM. In the first two years of life, we have a 20 percent prevalence of eczema. In your opinion, what is the best tool to combat this disease’s symptoms?
LE. Atopic dermatitis is an interesting and challenging disease that has a variety of features. Recently, there has been much emphasis on intrinsic abnormalities of the skin which impact on the skin function and may contribute to the inflammatory component of the disease. The inflammation of eczema causes many of the symptoms and is responsible for much of the disease’s impact on the individual and family. Standard therapy for eczema involves both good general skin care and the use of products that can minimize problems with the skin barrier, and can effectively control skin inflammation.

There also is a broad set of agents that can be useful for different components of the disease treatment. There are many anti-inflammatory therapies, including topical corticosteroids as well as non-steroid calciurin inhibitors and newer products that have both barrier dysfunction effects and anti-inflammatory effects.

EHM. Acne is probably the greatest concern for children maturing to adolescence. What are the implications of using a retinoid compared to other options?
LE. Retinoids are considered the standard first line therapy for most acnes. However, in pediatric dermatology, especially when we look at earlier acne, many times we will use benzyl peroxide or benzyl peroxide combination products as alternative first line agents. The general principle is that we can effectively treat most acnes, but we try to use the most efficient and cost effective therapies with a minimal amount of side effects, choosing our medicines based upon disease severity. So for the vast majority of acne, retinoids can be highly useful, and many times they may be used in combination with other agents, or in new combination formulations that include topical antibiotics or a benzyl peroxide along with the retinoids.

EHM. What do you think needs more focus in the future?
LE. There is an insufficient number of pediatric dermatologists to deliver both the necessary care for children’s dermatologic disease and to promote cutaneous health over a lifetime. There is shortage of pediatric dermatology training positions, as well a need for improved education of pediatricians and other generalists. We advocate the expansion of training of primary care physicians, pediatricians and generalists, as well as an increase in the number of pediatric dermatologists being produced by dermatology programs.

While there are many people who would be interested in joining the field of pediatric dermatology, there is restricted funding to allow their training. More funding would certainly be helpful in order to get more people ‘through the door’ and out into pediatric dermatology practice.

Dr. Lawrence F. Eichenfield is Chief of Pediatric and Adolescent Dermatology at Rady Children’s Hospital, San Diego, and Professor of Pediatrics and Medicine (Dermatology) at the University of California, San Diego (UCSD) School of Medicine. He earned his medical degree from Mount Sinai School of Medicine in New York, was a pediatric resident and chief resident at Children’s Hospital of Philadelphia, and completed dermatology training at the Hospital of the University of Pennsylvania.