Key clinical point: Tralokinumab led to clinically meaningful responses in adults with moderate-to-severe atopic dermatitis (AD) who failed to achieve an Investigator’s Global Assessment (IGA) score of 0 or 1 at 16 weeks without rescue medication.

Major finding: At week 16, a significantly greater proportion of patients receiving tralokinumab vs placebo achieved ≥ 50% improvement in the Eczema Area and Severity Index scores (33.0% vs 13.0%; P < .0001) and ≥ 3-point improvement in the itch Numerical Rating Scale scores (22.6% vs 9.4%; P < .0001).

Study details: This post hoc analysis of data from ECZTRA 1 and 2 trials included adults with moderate-to-severe AD who were randomized to receive tralokinumab (n = 966) or placebo (n = 362) and failed to achieve an IGA score of 0 or 1 at week 16 without rescue medication.

Disclosures: ECZTRA 1 and 2 were sponsored by LEO Pharma A/S, Denmark. Several authors declared ties with LEO Pharma, among others. T Mark declared being an employee and stockholder of LEO Pharma A/S.

Source: Simpson EL et al. Tralokinumab provides clinically meaningful responses at week 16 in adults with moderate-to-severe atopic dermatitis who do not achieve IGA 0/1. Am J Clin Dermatol. 2023 (Oct 7). doi: 10.1007/s40257-023-00817-0

Key clinical point: Tralokinumab led to clinically meaningful responses in adults with moderate-to-severe atopic dermatitis (AD) who failed to achieve an Investigator’s Global Assessment (IGA) score of 0 or 1 at 16 weeks without rescue medication.

Major finding: At week 16, a significantly greater proportion of patients receiving tralokinumab vs placebo achieved ≥ 50% improvement in the Eczema Area and Severity Index scores (33.0% vs 13.0%; P < .0001) and ≥ 3-point improvement in the itch Numerical Rating Scale scores (22.6% vs 9.4%; P < .0001).

Study details: This post hoc analysis of data from ECZTRA 1 and 2 trials included adults with moderate-to-severe AD who were randomized to receive tralokinumab (n = 966) or placebo (n = 362) and failed to achieve an IGA score of 0 or 1 at week 16 without rescue medication.

Disclosures: ECZTRA 1 and 2 were sponsored by LEO Pharma A/S, Denmark. Several authors declared ties with LEO Pharma, among others. T Mark declared being an employee and stockholder of LEO Pharma A/S.

Source: Simpson EL et al. Tralokinumab provides clinically meaningful responses at week 16 in adults with moderate-to-severe atopic dermatitis who do not achieve IGA 0/1. Am J Clin Dermatol. 2023 (Oct 7). doi: 10.1007/s40257-023-00817-0

Key clinical point: Tralokinumab led to clinically meaningful responses in adults with moderate-to-severe atopic dermatitis (AD) who failed to achieve an Investigator’s Global Assessment (IGA) score of 0 or 1 at 16 weeks without rescue medication.

Major finding: At week 16, a significantly greater proportion of patients receiving tralokinumab vs placebo achieved ≥ 50% improvement in the Eczema Area and Severity Index scores (33.0% vs 13.0%; P < .0001) and ≥ 3-point improvement in the itch Numerical Rating Scale scores (22.6% vs 9.4%; P < .0001).

Study details: This post hoc analysis of data from ECZTRA 1 and 2 trials included adults with moderate-to-severe AD who were randomized to receive tralokinumab (n = 966) or placebo (n = 362) and failed to achieve an IGA score of 0 or 1 at week 16 without rescue medication.

Disclosures: ECZTRA 1 and 2 were sponsored by LEO Pharma A/S, Denmark. Several authors declared ties with LEO Pharma, among others. T Mark declared being an employee and stockholder of LEO Pharma A/S.

Source: Simpson EL et al. Tralokinumab provides clinically meaningful responses at week 16 in adults with moderate-to-severe atopic dermatitis who do not achieve IGA 0/1. Am J Clin Dermatol. 2023 (Oct 7). doi: 10.1007/s40257-023-00817-0

Key clinical point: Methotrexate treatment decreased epidermal hyperplasia and altered the cutaneous expression of pruritus-related inflammatory cytokines and receptors, including interleukin-31 (IL-31) and IL-31 alpha receptor subunits (RA), in adults with moderate-to-severe refractory atopic dermatitis (AD).

Major finding: At 24 weeks of treatment, methotrexate led to a significant increase in IL-31RA expression in the epidermis (P = .016), decrease in IL-31 gene expression in lesional skin (P = .019), and reduction in the mean epidermal thickness (P = .021).

Study details: Findings are from a prospective cohort study including 12 adults with moderate-to-severe refractory AD who orally received 15 mg methotrexate per week and were matched with 10 control individuals without AD.

Disclosures: This study was supported by Fundo de Apoio à Dermatologia de São Paulo, Brazil. The authors declared no conflicts of interest.

Source: Samorano LP et al. Methotrexate for refractory adult atopic dermatitis leads to alterations in cutaneous IL-31 and IL-31RA expression. An Bras Dermatol. 2023 (Sep 18). doi: 10.1016/j.abd.2023.01.002

Key clinical point: Methotrexate treatment decreased epidermal hyperplasia and altered the cutaneous expression of pruritus-related inflammatory cytokines and receptors, including interleukin-31 (IL-31) and IL-31 alpha receptor subunits (RA), in adults with moderate-to-severe refractory atopic dermatitis (AD).

Major finding: At 24 weeks of treatment, methotrexate led to a significant increase in IL-31RA expression in the epidermis (P = .016), decrease in IL-31 gene expression in lesional skin (P = .019), and reduction in the mean epidermal thickness (P = .021).

Study details: Findings are from a prospective cohort study including 12 adults with moderate-to-severe refractory AD who orally received 15 mg methotrexate per week and were matched with 10 control individuals without AD.

Disclosures: This study was supported by Fundo de Apoio à Dermatologia de São Paulo, Brazil. The authors declared no conflicts of interest.

Source: Samorano LP et al. Methotrexate for refractory adult atopic dermatitis leads to alterations in cutaneous IL-31 and IL-31RA expression. An Bras Dermatol. 2023 (Sep 18). doi: 10.1016/j.abd.2023.01.002

Key clinical point: Methotrexate treatment decreased epidermal hyperplasia and altered the cutaneous expression of pruritus-related inflammatory cytokines and receptors, including interleukin-31 (IL-31) and IL-31 alpha receptor subunits (RA), in adults with moderate-to-severe refractory atopic dermatitis (AD).

Major finding: At 24 weeks of treatment, methotrexate led to a significant increase in IL-31RA expression in the epidermis (P = .016), decrease in IL-31 gene expression in lesional skin (P = .019), and reduction in the mean epidermal thickness (P = .021).

Study details: Findings are from a prospective cohort study including 12 adults with moderate-to-severe refractory AD who orally received 15 mg methotrexate per week and were matched with 10 control individuals without AD.

Disclosures: This study was supported by Fundo de Apoio à Dermatologia de São Paulo, Brazil. The authors declared no conflicts of interest.

Source: Samorano LP et al. Methotrexate for refractory adult atopic dermatitis leads to alterations in cutaneous IL-31 and IL-31RA expression. An Bras Dermatol. 2023 (Sep 18). doi: 10.1016/j.abd.2023.01.002

Key clinical point: Topical treatment with tacrolimus vs hydrocortisone was more efficacious in reducing inflammatory marker levels and had a better safety profile in children with atopic dermatitis (AD).

Major finding: After 3 weeks, patients receiving tacrolimus vs hydrocortisone showed a significantly greater decrease in the mean serum levels of IL-10 (P = .05), IL-17 (P = .021), and IL-23 (P = .03), lower rates of skin atrophy (P < .05), and higher but manageable incidences of mild-to-moderate transient stinging and erythema (P < .05).

Study details: Findings are from a prospective randomized clinical trial including 200 children with AD (age 2-16 years) who were randomly assigned in a 1:1 ratio to receive either 0.03% topical tacrolimus ointment or 1% hydrocortisone cream twice daily.

Disclosures: This study did not disclose any funding source. The authors declared no conflicts of interest.

Source: Mohamed AA et al. A comparative randomized clinical trial evaluating the efficacy and safety of tacrolimus versus hydrocortisone as a topical treatment of atopic dermatitis in children. Front Pharmacol. 2023;14:1202325 (Sep 20). doi: 10.3389/fphar.2023.1202325

Key clinical point: Topical treatment with tacrolimus vs hydrocortisone was more efficacious in reducing inflammatory marker levels and had a better safety profile in children with atopic dermatitis (AD).

Major finding: After 3 weeks, patients receiving tacrolimus vs hydrocortisone showed a significantly greater decrease in the mean serum levels of IL-10 (P = .05), IL-17 (P = .021), and IL-23 (P = .03), lower rates of skin atrophy (P < .05), and higher but manageable incidences of mild-to-moderate transient stinging and erythema (P < .05).

Study details: Findings are from a prospective randomized clinical trial including 200 children with AD (age 2-16 years) who were randomly assigned in a 1:1 ratio to receive either 0.03% topical tacrolimus ointment or 1% hydrocortisone cream twice daily.

Disclosures: This study did not disclose any funding source. The authors declared no conflicts of interest.

Source: Mohamed AA et al. A comparative randomized clinical trial evaluating the efficacy and safety of tacrolimus versus hydrocortisone as a topical treatment of atopic dermatitis in children. Front Pharmacol. 2023;14:1202325 (Sep 20). doi: 10.3389/fphar.2023.1202325

Key clinical point: Topical treatment with tacrolimus vs hydrocortisone was more efficacious in reducing inflammatory marker levels and had a better safety profile in children with atopic dermatitis (AD).

Major finding: After 3 weeks, patients receiving tacrolimus vs hydrocortisone showed a significantly greater decrease in the mean serum levels of IL-10 (P = .05), IL-17 (P = .021), and IL-23 (P = .03), lower rates of skin atrophy (P < .05), and higher but manageable incidences of mild-to-moderate transient stinging and erythema (P < .05).

Study details: Findings are from a prospective randomized clinical trial including 200 children with AD (age 2-16 years) who were randomly assigned in a 1:1 ratio to receive either 0.03% topical tacrolimus ointment or 1% hydrocortisone cream twice daily.

Disclosures: This study did not disclose any funding source. The authors declared no conflicts of interest.

Source: Mohamed AA et al. A comparative randomized clinical trial evaluating the efficacy and safety of tacrolimus versus hydrocortisone as a topical treatment of atopic dermatitis in children. Front Pharmacol. 2023;14:1202325 (Sep 20). doi: 10.3389/fphar.2023.1202325

Key clinical point: Atopic dermatitis (AD) negatively affects the prognosis, quality of life (QoL), and work life in young workers with occupational contact dermatitis (OCD).

Major finding: The prevalence of previously diagnosed AD was 41.8%. A higher proportion of workers with vs without AD experienced eczema during the last 3 months of response submission (adjusted odds ratio [aOR] 1.7; P < .001) and reported that OCD had negatively affected their choice of jobs and occupations (aOR 1.4; P < .001). Workers with vs without AD had significantly higher mean scores in the emotions (P < .01) and symptoms (P < .001) subscales of the Skindex-29 assessment of QoL.

Study details: Findings are from a retrospective questionnaire-based study including 2392 workers age < 35 years with OCD who answered a question about being previously diagnosed with AD.

Disclosures: This study was funded by the Danish Working Environment Research Fund. The authors declared no conflicts of interest.

Source: Dietz JB et al. Impact of atopic dermatitis on occupational contact dermatitis among young people: A retrospective cohort study. Contact Dermatitis. 2023 (Sep 26). doi: 10.1111/cod.14426

Key clinical point: Atopic dermatitis (AD) negatively affects the prognosis, quality of life (QoL), and work life in young workers with occupational contact dermatitis (OCD).

Major finding: The prevalence of previously diagnosed AD was 41.8%. A higher proportion of workers with vs without AD experienced eczema during the last 3 months of response submission (adjusted odds ratio [aOR] 1.7; P < .001) and reported that OCD had negatively affected their choice of jobs and occupations (aOR 1.4; P < .001). Workers with vs without AD had significantly higher mean scores in the emotions (P < .01) and symptoms (P < .001) subscales of the Skindex-29 assessment of QoL.

Study details: Findings are from a retrospective questionnaire-based study including 2392 workers age < 35 years with OCD who answered a question about being previously diagnosed with AD.

Disclosures: This study was funded by the Danish Working Environment Research Fund. The authors declared no conflicts of interest.

Source: Dietz JB et al. Impact of atopic dermatitis on occupational contact dermatitis among young people: A retrospective cohort study. Contact Dermatitis. 2023 (Sep 26). doi: 10.1111/cod.14426

Key clinical point: Atopic dermatitis (AD) negatively affects the prognosis, quality of life (QoL), and work life in young workers with occupational contact dermatitis (OCD).

Major finding: The prevalence of previously diagnosed AD was 41.8%. A higher proportion of workers with vs without AD experienced eczema during the last 3 months of response submission (adjusted odds ratio [aOR] 1.7; P < .001) and reported that OCD had negatively affected their choice of jobs and occupations (aOR 1.4; P < .001). Workers with vs without AD had significantly higher mean scores in the emotions (P < .01) and symptoms (P < .001) subscales of the Skindex-29 assessment of QoL.

Study details: Findings are from a retrospective questionnaire-based study including 2392 workers age < 35 years with OCD who answered a question about being previously diagnosed with AD.

Disclosures: This study was funded by the Danish Working Environment Research Fund. The authors declared no conflicts of interest.

Source: Dietz JB et al. Impact of atopic dermatitis on occupational contact dermatitis among young people: A retrospective cohort study. Contact Dermatitis. 2023 (Sep 26). doi: 10.1111/cod.14426

Key clinical point: Xyloglucan and pea protein (XG-PP)-based topical treatment shows safety and efficacy outcomes comparable with those of hydrocortisone in pediatric patients with atopic dermatitis (AD).

Major finding: At 8 and 15 days of treatment, both XG-PP and hydrocortisone led to significant decreases in the AD Severity Index (ADSI) score (all P = .00001). Both treatment arms showed similar decrease in ADSI scores at 8 (P = .91) and 15 (P = .92) days. No adverse events were reported in the XG-PP treatment arm.

Study details: Findings are from a prospective multicenter study including 42 pediatric patients with mild-to-moderate AD (age 6 months-12 years) who were randomly assigned to receive either topical XG-PP-based cream or hydrocortisone twice daily for 14 consecutive days.

Disclosures: This study was sponsored by Novintethical Pharma SA. The authors declared no conflicts of interest.

Source: Sowlati M et al. Efficacy and tolerability of a novel topical treatment containing pea protein and xyloglucan in the management of atopic dermatitis in children: A prospective, multicenter clinical study. Dermatol Ther (Heidelb). 2023 (Sep 23). doi: 10.1007/s13555-023-01035-6

Key clinical point: Xyloglucan and pea protein (XG-PP)-based topical treatment shows safety and efficacy outcomes comparable with those of hydrocortisone in pediatric patients with atopic dermatitis (AD).

Major finding: At 8 and 15 days of treatment, both XG-PP and hydrocortisone led to significant decreases in the AD Severity Index (ADSI) score (all P = .00001). Both treatment arms showed similar decrease in ADSI scores at 8 (P = .91) and 15 (P = .92) days. No adverse events were reported in the XG-PP treatment arm.

Study details: Findings are from a prospective multicenter study including 42 pediatric patients with mild-to-moderate AD (age 6 months-12 years) who were randomly assigned to receive either topical XG-PP-based cream or hydrocortisone twice daily for 14 consecutive days.

Disclosures: This study was sponsored by Novintethical Pharma SA. The authors declared no conflicts of interest.

Source: Sowlati M et al. Efficacy and tolerability of a novel topical treatment containing pea protein and xyloglucan in the management of atopic dermatitis in children: A prospective, multicenter clinical study. Dermatol Ther (Heidelb). 2023 (Sep 23). doi: 10.1007/s13555-023-01035-6

Key clinical point: Xyloglucan and pea protein (XG-PP)-based topical treatment shows safety and efficacy outcomes comparable with those of hydrocortisone in pediatric patients with atopic dermatitis (AD).

Major finding: At 8 and 15 days of treatment, both XG-PP and hydrocortisone led to significant decreases in the AD Severity Index (ADSI) score (all P = .00001). Both treatment arms showed similar decrease in ADSI scores at 8 (P = .91) and 15 (P = .92) days. No adverse events were reported in the XG-PP treatment arm.

Study details: Findings are from a prospective multicenter study including 42 pediatric patients with mild-to-moderate AD (age 6 months-12 years) who were randomly assigned to receive either topical XG-PP-based cream or hydrocortisone twice daily for 14 consecutive days.

Disclosures: This study was sponsored by Novintethical Pharma SA. The authors declared no conflicts of interest.

Source: Sowlati M et al. Efficacy and tolerability of a novel topical treatment containing pea protein and xyloglucan in the management of atopic dermatitis in children: A prospective, multicenter clinical study. Dermatol Ther (Heidelb). 2023 (Sep 23). doi: 10.1007/s13555-023-01035-6

Key clinical point: Patients with atopic dermatitis (AD) have an increased risk for multiple neuropsychiatric conditions; however, the risk profiles for specific neuropsychiatric conditions differ with AD severity.

Major finding: Adults with AD (of any severity level) vs without AD had a higher risk for anxiety (adjusted hazard ratio [aHR] 1.14, 95% CI 1.13-1.15), depression (aHR 1.14, 95% CI 1.13-1.15), and obsessive-compulsive disorder (aHR 1.48, 95% CI 1.38-1.58); the risk for autism increased in patients with mild (aHR 1.55; 95% CI 1.26-1.89) and moderate (aHR 1.40; 95% CI 1.07-1.83) AD and that for attention-deficit/hyperactivity disorder increased in those with mild AD (aHR 1.27; 95% CI 1.03-1.55].

Study details: This population-based cohort study included 625,083 adults with AD who were matched with 2,678,888 control adults without AD.

Disclosures: This study was supported by a contract from Pfizer, Inc. Some authors declared receiving research or fellowship funding or consultation honoraria from various sources, including Pfizer. AR Lemeshow declared being an employee of Pfizer.

Source: Wan J et al. Neuropsychiatric disorders in adults with atopic dermatitis: A population-based cohort study. J Eur Acad Dermatol Venereol. 2023 (Sep 20). doi: 10.1111/jdv.19518

Key clinical point: Patients with atopic dermatitis (AD) have an increased risk for multiple neuropsychiatric conditions; however, the risk profiles for specific neuropsychiatric conditions differ with AD severity.

Major finding: Adults with AD (of any severity level) vs without AD had a higher risk for anxiety (adjusted hazard ratio [aHR] 1.14, 95% CI 1.13-1.15), depression (aHR 1.14, 95% CI 1.13-1.15), and obsessive-compulsive disorder (aHR 1.48, 95% CI 1.38-1.58); the risk for autism increased in patients with mild (aHR 1.55; 95% CI 1.26-1.89) and moderate (aHR 1.40; 95% CI 1.07-1.83) AD and that for attention-deficit/hyperactivity disorder increased in those with mild AD (aHR 1.27; 95% CI 1.03-1.55].

Study details: This population-based cohort study included 625,083 adults with AD who were matched with 2,678,888 control adults without AD.

Disclosures: This study was supported by a contract from Pfizer, Inc. Some authors declared receiving research or fellowship funding or consultation honoraria from various sources, including Pfizer. AR Lemeshow declared being an employee of Pfizer.

Source: Wan J et al. Neuropsychiatric disorders in adults with atopic dermatitis: A population-based cohort study. J Eur Acad Dermatol Venereol. 2023 (Sep 20). doi: 10.1111/jdv.19518

Key clinical point: Patients with atopic dermatitis (AD) have an increased risk for multiple neuropsychiatric conditions; however, the risk profiles for specific neuropsychiatric conditions differ with AD severity.

Major finding: Adults with AD (of any severity level) vs without AD had a higher risk for anxiety (adjusted hazard ratio [aHR] 1.14, 95% CI 1.13-1.15), depression (aHR 1.14, 95% CI 1.13-1.15), and obsessive-compulsive disorder (aHR 1.48, 95% CI 1.38-1.58); the risk for autism increased in patients with mild (aHR 1.55; 95% CI 1.26-1.89) and moderate (aHR 1.40; 95% CI 1.07-1.83) AD and that for attention-deficit/hyperactivity disorder increased in those with mild AD (aHR 1.27; 95% CI 1.03-1.55].

Study details: This population-based cohort study included 625,083 adults with AD who were matched with 2,678,888 control adults without AD.

Disclosures: This study was supported by a contract from Pfizer, Inc. Some authors declared receiving research or fellowship funding or consultation honoraria from various sources, including Pfizer. AR Lemeshow declared being an employee of Pfizer.

Source: Wan J et al. Neuropsychiatric disorders in adults with atopic dermatitis: A population-based cohort study. J Eur Acad Dermatol Venereol. 2023 (Sep 20). doi: 10.1111/jdv.19518

Key clinical point: Both ciclosporin and methotrexate were effective against severe atopic dermatitis (AD) in children, but ciclosporin resulted in a more rapid response whereas methotrexate led to more sustained disease control even after treatment discontinuation.

Major finding: At 12 weeks, a significantly higher proportion of patients achieved 50% improvement in Objective Severity Scoring of Atopic Dermatitis scores (o-SCORAD-50) with ciclosporin vs methotrexate (P = .012). However, at 60 weeks, the proportion of patients who achieved o-SCORAD-50 was higher with methotrexate vs ciclosporin (P = .022). Adverse event rates were comparable in both groups.

Study details: The TREatment of severe Atopic Eczema Trial included 103 children with severe AD (age 2-16 years) who were unresponsive to topical treatments and were randomly assigned to receive ciclosporin or methotrexate.

Disclosures: This study was funded by the UK Medical Research Council/National Institute for Health Research (NIHR). Some authors, including the lead author, declared receiving consulting fees, advisory fees, or research funding from various sources, including UK NIHR.

Source: Flohr C et al and the TREAT Trial Investigators. Efficacy and safety of ciclosporin versus methotrexate in the treatment of severe atopic dermatitis in children and young people (TREAT): A multicentre, parallel group, assessor-blinded clinical trial. Br J Dermatol. 2023 (Sep 19). doi: 10.1093/bjd/ljad281

Key clinical point: Both ciclosporin and methotrexate were effective against severe atopic dermatitis (AD) in children, but ciclosporin resulted in a more rapid response whereas methotrexate led to more sustained disease control even after treatment discontinuation.

Major finding: At 12 weeks, a significantly higher proportion of patients achieved 50% improvement in Objective Severity Scoring of Atopic Dermatitis scores (o-SCORAD-50) with ciclosporin vs methotrexate (P = .012). However, at 60 weeks, the proportion of patients who achieved o-SCORAD-50 was higher with methotrexate vs ciclosporin (P = .022). Adverse event rates were comparable in both groups.

Study details: The TREatment of severe Atopic Eczema Trial included 103 children with severe AD (age 2-16 years) who were unresponsive to topical treatments and were randomly assigned to receive ciclosporin or methotrexate.

Disclosures: This study was funded by the UK Medical Research Council/National Institute for Health Research (NIHR). Some authors, including the lead author, declared receiving consulting fees, advisory fees, or research funding from various sources, including UK NIHR.

Source: Flohr C et al and the TREAT Trial Investigators. Efficacy and safety of ciclosporin versus methotrexate in the treatment of severe atopic dermatitis in children and young people (TREAT): A multicentre, parallel group, assessor-blinded clinical trial. Br J Dermatol. 2023 (Sep 19). doi: 10.1093/bjd/ljad281

Key clinical point: Both ciclosporin and methotrexate were effective against severe atopic dermatitis (AD) in children, but ciclosporin resulted in a more rapid response whereas methotrexate led to more sustained disease control even after treatment discontinuation.

Major finding: At 12 weeks, a significantly higher proportion of patients achieved 50% improvement in Objective Severity Scoring of Atopic Dermatitis scores (o-SCORAD-50) with ciclosporin vs methotrexate (P = .012). However, at 60 weeks, the proportion of patients who achieved o-SCORAD-50 was higher with methotrexate vs ciclosporin (P = .022). Adverse event rates were comparable in both groups.

Study details: The TREatment of severe Atopic Eczema Trial included 103 children with severe AD (age 2-16 years) who were unresponsive to topical treatments and were randomly assigned to receive ciclosporin or methotrexate.

Disclosures: This study was funded by the UK Medical Research Council/National Institute for Health Research (NIHR). Some authors, including the lead author, declared receiving consulting fees, advisory fees, or research funding from various sources, including UK NIHR.

Source: Flohr C et al and the TREAT Trial Investigators. Efficacy and safety of ciclosporin versus methotrexate in the treatment of severe atopic dermatitis in children and young people (TREAT): A multicentre, parallel group, assessor-blinded clinical trial. Br J Dermatol. 2023 (Sep 19). doi: 10.1093/bjd/ljad281

Key clinical point: Compared with children without atopic dermatitis (AD), those with AD are significantly more likely to have positive patch tests (PPT) and respond to ≥1 allergen on patch testing.

Major finding: Children with vs without AD were significantly more likely to have a longer duration of dermatitis (P < .0001), >1 PPT result (P = .005), a greater number of PPT overall (P = .012), and a more generalized distribution of dermatitis (P = .001) as well as PPT to bacitracin (P = .030), carba mix (diphenylguanidine, zinc dibutyldithiocarbamate, and zinc diethyldithiocarbamate) (P = .025), and cocamidopropyl betaine (P = .0007).

Study details: This retrospective case-control study included 615 children with AD and 297 children without AD.

Disclosures: This study was supported by the Dermatology Foundation, Evanston, IL. The authors declared no conflicts of interest.

Source: Johnson H et al. Prevalence of allergic contact dermatitis in children with and without atopic dermatitis: A multicenter retrospective case-control study. J Am Acad Dermatol. 2023;89(5):1007-1014 (Sep 25). doi: 10.1016/j.jaad.2023.06.048

Key clinical point: Compared with children without atopic dermatitis (AD), those with AD are significantly more likely to have positive patch tests (PPT) and respond to ≥1 allergen on patch testing.

Major finding: Children with vs without AD were significantly more likely to have a longer duration of dermatitis (P < .0001), >1 PPT result (P = .005), a greater number of PPT overall (P = .012), and a more generalized distribution of dermatitis (P = .001) as well as PPT to bacitracin (P = .030), carba mix (diphenylguanidine, zinc dibutyldithiocarbamate, and zinc diethyldithiocarbamate) (P = .025), and cocamidopropyl betaine (P = .0007).

Study details: This retrospective case-control study included 615 children with AD and 297 children without AD.

Disclosures: This study was supported by the Dermatology Foundation, Evanston, IL. The authors declared no conflicts of interest.

Source: Johnson H et al. Prevalence of allergic contact dermatitis in children with and without atopic dermatitis: A multicenter retrospective case-control study. J Am Acad Dermatol. 2023;89(5):1007-1014 (Sep 25). doi: 10.1016/j.jaad.2023.06.048

Key clinical point: Compared with children without atopic dermatitis (AD), those with AD are significantly more likely to have positive patch tests (PPT) and respond to ≥1 allergen on patch testing.

Major finding: Children with vs without AD were significantly more likely to have a longer duration of dermatitis (P < .0001), >1 PPT result (P = .005), a greater number of PPT overall (P = .012), and a more generalized distribution of dermatitis (P = .001) as well as PPT to bacitracin (P = .030), carba mix (diphenylguanidine, zinc dibutyldithiocarbamate, and zinc diethyldithiocarbamate) (P = .025), and cocamidopropyl betaine (P = .0007).

Study details: This retrospective case-control study included 615 children with AD and 297 children without AD.

Disclosures: This study was supported by the Dermatology Foundation, Evanston, IL. The authors declared no conflicts of interest.

Source: Johnson H et al. Prevalence of allergic contact dermatitis in children with and without atopic dermatitis: A multicenter retrospective case-control study. J Am Acad Dermatol. 2023;89(5):1007-1014 (Sep 25). doi: 10.1016/j.jaad.2023.06.048

Checking on the well-being of mothers is one of the important acknowledged aspects of primary pediatric care. “How are you doing?” directed to the child’s mother has long been considered an appropriate question. The AAP recommends several checks in the Bright Futures Guidelines, including conducting several formal screens for depression and asking about “getting time alone with your partner” as well as other supports.

But I have recently become aware of new data that changes my ideas about what we pediatricians need to be doing as part of our care for children and their families, especially in the first year: Considering the risks to the mother of dying.

Maternal mortality increased by 26.6% from 2000 to 2014 across the United States such that it is higher now than it was for our own mothers. The U.S. now has the highest rates of maternal mortality among high-income nations, especially for Black, American Indian, or Alaska Native women, those of lower socioeconomic status, and those under 18 or over 35 years old.

You may be thinking, well, that is an issue for ob.gyns. Indeed, the most common reasons for maternal death are cardiovascular: hemorrhage, hypertensive disorders, deep vein thrombosis, and stroke, all usually occurring at or in the first week after birth. You may have heard about sudden unexpected heart failure from postpartum cardiomyopathy, although rare (1 in 1,000-4,000), presenting from 1 month pre birth to 5 months post delivery, which is when we may be the main clinicians seeing the mother, not the ob.gyns. This can be easily missed since it presents with shortness of breath and decreased exercise tolerance, fatigue, palpitations, and/or leg swelling. Serious eclampsia may have only symptoms of headache or abdominal pain. All of these may easily be mistaken for lingering pregnancy symptoms. But in higher income countries, such as the U.S., 38% of maternal deaths occur from 8 to 42 days after birth, the period for fatal infections as well as cardiac complications. Elevated risk for all of these causes of mortality include Black race, obesity, tobacco use, congenital heart disease, and being older than 40.

As pediatric providers, we may see mothers along with their infants as newborns in the hospital, at day 2, at 2 weeks, or even at 1-2 months after birth, potentially before their one recommended postnatal obstetric visit at 3-8 weeks. Asking the mother how she is feeling at those times should not just be a social nicety but rather an additional check for serious postnatal complications.
 

Additional concerns

But wait, it gets worse.

Did you know that the leading cause of maternal death from pregnancy up to 1 year after a birth is homicide?

Maternal perinatal mortality figures have not usually included “perinatal-associated” deaths, a maternal death attributable to a condition that is unaffected by the pregnancy and occurring within 1 year of delivery (that I will cite as perinatal henceforth). While half of maternal deaths occur during pregnancy, another half occur in the year following. There were 3.62 homicides per 100,000 live births among females who were pregnant or within 1 year postpartum, 16% more than for similarly aged nonpregnant and nonpostpartum women (3.12 deaths/100,000 population, P < .05). Homicides made up 8.4% of reported perinatal maternal deaths from all causes, with a rate of 1.7 per 100,000 live births, twice the rate of any one of the other leading causes noted above. Black women had seven times the risk of perinatal homicide as that of White women. Females under 20, many of them our own pediatric patients, had a greater than six times higher risk and those aged 20-24 had a 65% higher risk of pregnancy-associated homicide across race and ethnic groups. Homicide is most likely before 21 weeks of pregnancy, decreases in the third trimester, but increases again after birth. Two-thirds of pregnancy-associated homicide deaths occurred in the home, with the perpetrator a current or prior partner (> 59%, with 98% being male), 45%-50% were associated with reported intimate partner violence (IPV), and the most common method was a firearm (55%). Often the same women had histories of substance abuse, serious mental illness, and/or prior IPV, all risk factors for pregnancy-associated deaths, including from homicide.

Homicide? “Not the mothers in my practice,” you may say, but, if not homicide, drug-related deaths (3.68 per 100,000 person-years) and suicide (1.42 per 100,000 person-years) together comprise 18% of all maternal deaths. Non-Hispanic White women, Medicaid-insured women, and women residing in smaller cities were especially likely to die from drugs or suicide. More than half (54.3%) of perinatal suicides involve intimate partner conflict, which increases the risk ninefold. Perinatal mood disorders, affecting up to 15% of pregnant and postpartum U.S. women, is also a risk factor in substance abuse, opioid overdose death, and suicide.

And substance use has gotten more dangerous with the increase in fentanyl lacing. Pregnancy-associated deaths (4%-10% of deaths) involving opioids more than doubled between 2007 and 2016, and, although the rates are higher for Black women, the increase has been greater for non-Hispanic White women. Two-thirds of those deaths occur between 6 and 12 months postpartum, on our watch. Although many women decrease substance use during pregnancy, they may fall back into substance use (rates increase 4 times by 7-12 months after delivery) and not continue to receive treatment. Although pharmacotherapy (e.g., methadone, buprenorphine treatment) is the current standard of care for opioid use disorder (OUD) during pregnancy, nearly half receiving treatment in publicly funded centers are not receiving these medications and others may lose insurance or access to pregnancy-related treatment programs after delivery, increasing risk of relapse. Stigma, and punitive or discriminatory approaches to pregnant women with OUD (e.g., jail, removal of children) can dissuade them from participating in treatment, increasing overdose risk.

It is important to note that in more than half of the 41 deaths from violent trauma in one study (including 22 homicides), obstetrical providers knew of or suspected IPV. Also, the vast majority (74%) of those who died by drugs or suicide had made one or more emergency department or hospital visit between their delivery and death, and 39% had made three or more visits. Without knowing if anything was done in those cases, we also know that, in addition to thorough, compassionate providers, there is sometimes segmentation of responsibility, insensitivity, discrimination, racism, stigma, inequity, lack of resources, lack of access, lack of payment mechanisms, legal issues for immigrants, time constraints, and other systemic deficits that may hinder effective care for these and subsequent women.
 

Awareness and action

What should we, who are primary care pediatric providers, do about these threats to the mothers and pregnant young women we care for? Clearly, their children, our main patients, would be terribly and permanently hurt by harm coming to their mothers – the extreme adverse childhood experiences and social determinants of health to which we are already committed.

I hope this article will help alert pediatric providers to what is being published, mainly as women’s health and public health issues.

First, we need awareness of the physical symptoms that may come up in our interactions with pregnant and postpartum women so that we can educate them and expedite any indicated emergency care.

Next, we need to expand our routine screening of mothers and pregnant women from just the most impactful social determinants of health (including depression, substance use, and IPV) to include anxiety, past suicide attempts and current suicidal ideation, and the presence of firearms, early and repeatedly in the first year of the child’s life. Adults and teens are more likely to disclose risk for sensitive issues through questionnaires than through interviews, perhaps even more so when the identified patient is their child rather than themselves. Any screen can have false negatives, so asking directly when risk is suspected is important. The reason for screening could be framed as caring for the caregiver who is the most important person for the child. It could be accompanied by acknowledging that pregnancy and the first year of life can be difficult for mothers and their partners and that we want to support them and connect them to resources, if needed. When substance use disorder is acknowledged, we should prescribe and teach about Narcan for overdose. When there is IPV, we should discuss firearm removal/locking as well as counseling on a personal safety plan.

Working as part of an on-site or virtual team that includes professionals who know about community resources and can coordinate care is essential, in addition to educating about 211 for services and 988 for suicide risk.

Finally, we can advocate and vote for programs, people, and laws that support and safeguard women and families, address substance use, and reduce access to firearms.
 

Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to MDedge News. E-mail her at pdnews@mdedge.com.

Checking on the well-being of mothers is one of the important acknowledged aspects of primary pediatric care. “How are you doing?” directed to the child’s mother has long been considered an appropriate question. The AAP recommends several checks in the Bright Futures Guidelines, including conducting several formal screens for depression and asking about “getting time alone with your partner” as well as other supports.

But I have recently become aware of new data that changes my ideas about what we pediatricians need to be doing as part of our care for children and their families, especially in the first year: Considering the risks to the mother of dying.

Maternal mortality increased by 26.6% from 2000 to 2014 across the United States such that it is higher now than it was for our own mothers. The U.S. now has the highest rates of maternal mortality among high-income nations, especially for Black, American Indian, or Alaska Native women, those of lower socioeconomic status, and those under 18 or over 35 years old.

You may be thinking, well, that is an issue for ob.gyns. Indeed, the most common reasons for maternal death are cardiovascular: hemorrhage, hypertensive disorders, deep vein thrombosis, and stroke, all usually occurring at or in the first week after birth. You may have heard about sudden unexpected heart failure from postpartum cardiomyopathy, although rare (1 in 1,000-4,000), presenting from 1 month pre birth to 5 months post delivery, which is when we may be the main clinicians seeing the mother, not the ob.gyns. This can be easily missed since it presents with shortness of breath and decreased exercise tolerance, fatigue, palpitations, and/or leg swelling. Serious eclampsia may have only symptoms of headache or abdominal pain. All of these may easily be mistaken for lingering pregnancy symptoms. But in higher income countries, such as the U.S., 38% of maternal deaths occur from 8 to 42 days after birth, the period for fatal infections as well as cardiac complications. Elevated risk for all of these causes of mortality include Black race, obesity, tobacco use, congenital heart disease, and being older than 40.

As pediatric providers, we may see mothers along with their infants as newborns in the hospital, at day 2, at 2 weeks, or even at 1-2 months after birth, potentially before their one recommended postnatal obstetric visit at 3-8 weeks. Asking the mother how she is feeling at those times should not just be a social nicety but rather an additional check for serious postnatal complications.
 

Additional concerns

But wait, it gets worse.

Did you know that the leading cause of maternal death from pregnancy up to 1 year after a birth is homicide?

Maternal perinatal mortality figures have not usually included “perinatal-associated” deaths, a maternal death attributable to a condition that is unaffected by the pregnancy and occurring within 1 year of delivery (that I will cite as perinatal henceforth). While half of maternal deaths occur during pregnancy, another half occur in the year following. There were 3.62 homicides per 100,000 live births among females who were pregnant or within 1 year postpartum, 16% more than for similarly aged nonpregnant and nonpostpartum women (3.12 deaths/100,000 population, P < .05). Homicides made up 8.4% of reported perinatal maternal deaths from all causes, with a rate of 1.7 per 100,000 live births, twice the rate of any one of the other leading causes noted above. Black women had seven times the risk of perinatal homicide as that of White women. Females under 20, many of them our own pediatric patients, had a greater than six times higher risk and those aged 20-24 had a 65% higher risk of pregnancy-associated homicide across race and ethnic groups. Homicide is most likely before 21 weeks of pregnancy, decreases in the third trimester, but increases again after birth. Two-thirds of pregnancy-associated homicide deaths occurred in the home, with the perpetrator a current or prior partner (> 59%, with 98% being male), 45%-50% were associated with reported intimate partner violence (IPV), and the most common method was a firearm (55%). Often the same women had histories of substance abuse, serious mental illness, and/or prior IPV, all risk factors for pregnancy-associated deaths, including from homicide.

Homicide? “Not the mothers in my practice,” you may say, but, if not homicide, drug-related deaths (3.68 per 100,000 person-years) and suicide (1.42 per 100,000 person-years) together comprise 18% of all maternal deaths. Non-Hispanic White women, Medicaid-insured women, and women residing in smaller cities were especially likely to die from drugs or suicide. More than half (54.3%) of perinatal suicides involve intimate partner conflict, which increases the risk ninefold. Perinatal mood disorders, affecting up to 15% of pregnant and postpartum U.S. women, is also a risk factor in substance abuse, opioid overdose death, and suicide.

And substance use has gotten more dangerous with the increase in fentanyl lacing. Pregnancy-associated deaths (4%-10% of deaths) involving opioids more than doubled between 2007 and 2016, and, although the rates are higher for Black women, the increase has been greater for non-Hispanic White women. Two-thirds of those deaths occur between 6 and 12 months postpartum, on our watch. Although many women decrease substance use during pregnancy, they may fall back into substance use (rates increase 4 times by 7-12 months after delivery) and not continue to receive treatment. Although pharmacotherapy (e.g., methadone, buprenorphine treatment) is the current standard of care for opioid use disorder (OUD) during pregnancy, nearly half receiving treatment in publicly funded centers are not receiving these medications and others may lose insurance or access to pregnancy-related treatment programs after delivery, increasing risk of relapse. Stigma, and punitive or discriminatory approaches to pregnant women with OUD (e.g., jail, removal of children) can dissuade them from participating in treatment, increasing overdose risk.

It is important to note that in more than half of the 41 deaths from violent trauma in one study (including 22 homicides), obstetrical providers knew of or suspected IPV. Also, the vast majority (74%) of those who died by drugs or suicide had made one or more emergency department or hospital visit between their delivery and death, and 39% had made three or more visits. Without knowing if anything was done in those cases, we also know that, in addition to thorough, compassionate providers, there is sometimes segmentation of responsibility, insensitivity, discrimination, racism, stigma, inequity, lack of resources, lack of access, lack of payment mechanisms, legal issues for immigrants, time constraints, and other systemic deficits that may hinder effective care for these and subsequent women.
 

Awareness and action

What should we, who are primary care pediatric providers, do about these threats to the mothers and pregnant young women we care for? Clearly, their children, our main patients, would be terribly and permanently hurt by harm coming to their mothers – the extreme adverse childhood experiences and social determinants of health to which we are already committed.

I hope this article will help alert pediatric providers to what is being published, mainly as women’s health and public health issues.

First, we need awareness of the physical symptoms that may come up in our interactions with pregnant and postpartum women so that we can educate them and expedite any indicated emergency care.

Next, we need to expand our routine screening of mothers and pregnant women from just the most impactful social determinants of health (including depression, substance use, and IPV) to include anxiety, past suicide attempts and current suicidal ideation, and the presence of firearms, early and repeatedly in the first year of the child’s life. Adults and teens are more likely to disclose risk for sensitive issues through questionnaires than through interviews, perhaps even more so when the identified patient is their child rather than themselves. Any screen can have false negatives, so asking directly when risk is suspected is important. The reason for screening could be framed as caring for the caregiver who is the most important person for the child. It could be accompanied by acknowledging that pregnancy and the first year of life can be difficult for mothers and their partners and that we want to support them and connect them to resources, if needed. When substance use disorder is acknowledged, we should prescribe and teach about Narcan for overdose. When there is IPV, we should discuss firearm removal/locking as well as counseling on a personal safety plan.

Working as part of an on-site or virtual team that includes professionals who know about community resources and can coordinate care is essential, in addition to educating about 211 for services and 988 for suicide risk.

Finally, we can advocate and vote for programs, people, and laws that support and safeguard women and families, address substance use, and reduce access to firearms.
 

Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to MDedge News. E-mail her at pdnews@mdedge.com.

Checking on the well-being of mothers is one of the important acknowledged aspects of primary pediatric care. “How are you doing?” directed to the child’s mother has long been considered an appropriate question. The AAP recommends several checks in the Bright Futures Guidelines, including conducting several formal screens for depression and asking about “getting time alone with your partner” as well as other supports.

But I have recently become aware of new data that changes my ideas about what we pediatricians need to be doing as part of our care for children and their families, especially in the first year: Considering the risks to the mother of dying.

Maternal mortality increased by 26.6% from 2000 to 2014 across the United States such that it is higher now than it was for our own mothers. The U.S. now has the highest rates of maternal mortality among high-income nations, especially for Black, American Indian, or Alaska Native women, those of lower socioeconomic status, and those under 18 or over 35 years old.

You may be thinking, well, that is an issue for ob.gyns. Indeed, the most common reasons for maternal death are cardiovascular: hemorrhage, hypertensive disorders, deep vein thrombosis, and stroke, all usually occurring at or in the first week after birth. You may have heard about sudden unexpected heart failure from postpartum cardiomyopathy, although rare (1 in 1,000-4,000), presenting from 1 month pre birth to 5 months post delivery, which is when we may be the main clinicians seeing the mother, not the ob.gyns. This can be easily missed since it presents with shortness of breath and decreased exercise tolerance, fatigue, palpitations, and/or leg swelling. Serious eclampsia may have only symptoms of headache or abdominal pain. All of these may easily be mistaken for lingering pregnancy symptoms. But in higher income countries, such as the U.S., 38% of maternal deaths occur from 8 to 42 days after birth, the period for fatal infections as well as cardiac complications. Elevated risk for all of these causes of mortality include Black race, obesity, tobacco use, congenital heart disease, and being older than 40.

As pediatric providers, we may see mothers along with their infants as newborns in the hospital, at day 2, at 2 weeks, or even at 1-2 months after birth, potentially before their one recommended postnatal obstetric visit at 3-8 weeks. Asking the mother how she is feeling at those times should not just be a social nicety but rather an additional check for serious postnatal complications.
 

Additional concerns

But wait, it gets worse.

Did you know that the leading cause of maternal death from pregnancy up to 1 year after a birth is homicide?

Maternal perinatal mortality figures have not usually included “perinatal-associated” deaths, a maternal death attributable to a condition that is unaffected by the pregnancy and occurring within 1 year of delivery (that I will cite as perinatal henceforth). While half of maternal deaths occur during pregnancy, another half occur in the year following. There were 3.62 homicides per 100,000 live births among females who were pregnant or within 1 year postpartum, 16% more than for similarly aged nonpregnant and nonpostpartum women (3.12 deaths/100,000 population, P < .05). Homicides made up 8.4% of reported perinatal maternal deaths from all causes, with a rate of 1.7 per 100,000 live births, twice the rate of any one of the other leading causes noted above. Black women had seven times the risk of perinatal homicide as that of White women. Females under 20, many of them our own pediatric patients, had a greater than six times higher risk and those aged 20-24 had a 65% higher risk of pregnancy-associated homicide across race and ethnic groups. Homicide is most likely before 21 weeks of pregnancy, decreases in the third trimester, but increases again after birth. Two-thirds of pregnancy-associated homicide deaths occurred in the home, with the perpetrator a current or prior partner (> 59%, with 98% being male), 45%-50% were associated with reported intimate partner violence (IPV), and the most common method was a firearm (55%). Often the same women had histories of substance abuse, serious mental illness, and/or prior IPV, all risk factors for pregnancy-associated deaths, including from homicide.

Homicide? “Not the mothers in my practice,” you may say, but, if not homicide, drug-related deaths (3.68 per 100,000 person-years) and suicide (1.42 per 100,000 person-years) together comprise 18% of all maternal deaths. Non-Hispanic White women, Medicaid-insured women, and women residing in smaller cities were especially likely to die from drugs or suicide. More than half (54.3%) of perinatal suicides involve intimate partner conflict, which increases the risk ninefold. Perinatal mood disorders, affecting up to 15% of pregnant and postpartum U.S. women, is also a risk factor in substance abuse, opioid overdose death, and suicide.

And substance use has gotten more dangerous with the increase in fentanyl lacing. Pregnancy-associated deaths (4%-10% of deaths) involving opioids more than doubled between 2007 and 2016, and, although the rates are higher for Black women, the increase has been greater for non-Hispanic White women. Two-thirds of those deaths occur between 6 and 12 months postpartum, on our watch. Although many women decrease substance use during pregnancy, they may fall back into substance use (rates increase 4 times by 7-12 months after delivery) and not continue to receive treatment. Although pharmacotherapy (e.g., methadone, buprenorphine treatment) is the current standard of care for opioid use disorder (OUD) during pregnancy, nearly half receiving treatment in publicly funded centers are not receiving these medications and others may lose insurance or access to pregnancy-related treatment programs after delivery, increasing risk of relapse. Stigma, and punitive or discriminatory approaches to pregnant women with OUD (e.g., jail, removal of children) can dissuade them from participating in treatment, increasing overdose risk.

It is important to note that in more than half of the 41 deaths from violent trauma in one study (including 22 homicides), obstetrical providers knew of or suspected IPV. Also, the vast majority (74%) of those who died by drugs or suicide had made one or more emergency department or hospital visit between their delivery and death, and 39% had made three or more visits. Without knowing if anything was done in those cases, we also know that, in addition to thorough, compassionate providers, there is sometimes segmentation of responsibility, insensitivity, discrimination, racism, stigma, inequity, lack of resources, lack of access, lack of payment mechanisms, legal issues for immigrants, time constraints, and other systemic deficits that may hinder effective care for these and subsequent women.
 

Awareness and action

What should we, who are primary care pediatric providers, do about these threats to the mothers and pregnant young women we care for? Clearly, their children, our main patients, would be terribly and permanently hurt by harm coming to their mothers – the extreme adverse childhood experiences and social determinants of health to which we are already committed.

I hope this article will help alert pediatric providers to what is being published, mainly as women’s health and public health issues.

First, we need awareness of the physical symptoms that may come up in our interactions with pregnant and postpartum women so that we can educate them and expedite any indicated emergency care.

Next, we need to expand our routine screening of mothers and pregnant women from just the most impactful social determinants of health (including depression, substance use, and IPV) to include anxiety, past suicide attempts and current suicidal ideation, and the presence of firearms, early and repeatedly in the first year of the child’s life. Adults and teens are more likely to disclose risk for sensitive issues through questionnaires than through interviews, perhaps even more so when the identified patient is their child rather than themselves. Any screen can have false negatives, so asking directly when risk is suspected is important. The reason for screening could be framed as caring for the caregiver who is the most important person for the child. It could be accompanied by acknowledging that pregnancy and the first year of life can be difficult for mothers and their partners and that we want to support them and connect them to resources, if needed. When substance use disorder is acknowledged, we should prescribe and teach about Narcan for overdose. When there is IPV, we should discuss firearm removal/locking as well as counseling on a personal safety plan.

Working as part of an on-site or virtual team that includes professionals who know about community resources and can coordinate care is essential, in addition to educating about 211 for services and 988 for suicide risk.

Finally, we can advocate and vote for programs, people, and laws that support and safeguard women and families, address substance use, and reduce access to firearms.
 

Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to MDedge News. E-mail her at pdnews@mdedge.com.

This transcript has been edited for clarity.

Dear colleagues, I’m Hans-Christoph Diener from the Faculty of Medicine at the University of Duisburg-Essen in Germany. I would like to give you an update on what was reported during the International Headache Congress in Seoul in September.
 

CGRP receptor agonists

Let me start with the treatment of acute migraine attacks. Until recently, we had analgesics, nonsteroidal anti-inflammatory drugs like ibuprofen, ergot alkaloids, and triptans. There are new developments, which are small molecules that are antagonists at the calcitonin gene-related peptide (CGRP) receptor. At the moment, we have three of them: rimegepant 75 mg, ubrogepant 50 mg or 100 mg, and zavegepant (a nasal spray) 10 mg.

These are all effective and superior to placebo. The 2-hour pain-free rate is somewhere between 25% and 30%. They have very few side effects; these include a little bit of nausea, somnolence, nasopharyngitis, and for zavegepant, the nasal spray, taste disturbance. In indirect comparisons, the so-called gepants are about as effective as ibuprofen and aspirin, and they seem to be less effective than sumatriptan 100 mg.

Unfortunately, until now, we have no direct comparison with triptans and we have no data demonstrating whether they are effective in people where triptans do not work. The major shortcoming is the cost in the United States. The cost per tablet or nasal spray is somewhere between $80 and $200. This means we definitely need more studies for these gepants.
 

Migraine prophylaxis

Let me move to the prophylaxis of migraine with drugs. Previously and still, we have all medications like beta-blockers, flunarizine, topiramate, valproic acid, amitriptyline, and candesartan, and for chronic migraine, onabotulinumtoxinA. We have now 5 years’ experience with the monoclonal antibodies against CGRP or the CGRP receptor like eptinezumab, erenumab, fremanezumab, and galcanezumab.

These are all equally effective. They reduce migraine-days between 3 and 7 per month. They are effective both in episodic and chronic migraine, and most importantly, they are effective in people with medication overuse headaches. The 50% responder rates are somewhere between 40% and 60%, and there are no significant differences between the four monoclonal antibodies.

The major advantage is a very good tolerability profile; very few patients terminate treatment because of adverse events. There has been, with one exception, no direct comparison of the monoclonal antibodies with traditional migraine preventive drugs or onabotulinumtoxinA. The only exception is a trial that compared topiramate and erenumab, showing that erenumab was definitely more effective and better tolerated.

At the moment, the recommendation is to use these monoclonal antibodies for 12 months in episodic migraine and 24 months in chronic migraine and then pause. It usually turns out that between 50% and 70% of these patients need to continue the treatment. If they are not working, there is a possibility to switch between the monoclonal antibodies, and the success rate after this is somewhere between 15% and 30%.

Gepants were also developed for the prevention of migraine. Here, we have rimegepant 75 mg every other day or atogepant 60 mg daily. They are effective, but in indirect comparisons, they are less effective than the monoclonal antibodies. At present, we have no comparative trials with monoclonal antibodies or the traditional migraine preventive drugs.

Potential patients are those who have needle phobia or patients who do not respond to monoclonal antibodies. Again, the biggest shortcoming is cost in the United States. The cost per year for migraine prevention or prophylaxis is between $12,000 and $20,000.

Finally, we also had very exciting news. There is a new therapeutic approach via PACAP. PACAP is pituitary adenylate cyclase-activating polypeptide, which has similar biological actions as CGRP but with additional actions. It could very well be that people who do not respond to a monoclonal antibody would respond to a monoclonal antibody against PACAP.

At the congress, the first randomized, placebo-controlled trial with a monoclonal antibody against PACAP was presented. This monoclonal antibody was effective in a population of people in whom prior preventive therapy had failed. A phase 3 study is planned, and most probably the PACAP monoclonal could work in people who do not respond to monoclonal antibodies against CGRP.

Dear colleagues, we have now many choices for the acute treatment of migraine and migraine prophylaxis. We have new kids on the block, and we have to learn more about how to use these drugs, their benefits, and their shortcomings.

He has disclosed the following relevant financial relationships:Received honoraria for participation in clinical trials, contribution to advisory boards or oral presentations from: Abbott; Addex Pharma; Alder; Allergan; Almirall; Amgen; Autonomic Technology; AstraZeneca; Bayer Vital; Berlin Chemie; Bristol-Myers Squibb; Boehringer Ingelheim; Chordate; CoAxia; Corimmun; Covidien; Coherex; CoLucid; Daiichi-Sankyo; D-Pharm; Electrocore; Fresenius; GlaxoSmithKline; Grunenthal; Janssen-Cilag; Labrys Biologics Lilly; La Roche; 3M Medica; MSD; Medtronic; Menarini; MindFrame; Minster; Neuroscore; Neurobiological Technologies; Novartis; Novo Nordisk; Johnson & Johnson; Knoll; Paion; Parke-Davis; Pierre Fabre; Pfizer; Schaper and Brummer; Sanofi-Aventis; Schering-Plough; Servier; Solvay; Syngis; St. Jude; Talecris; Thrombogenics; WebMD Global; Weber and Weber; Wyeth; and Yamanouchi.

Dr. Diener is professor, department of neurology, Stroke Center-Headache Center, University Duisburg-Essen (Germany).

A version of this article appeared on Medscape.com.

This transcript has been edited for clarity.

Dear colleagues, I’m Hans-Christoph Diener from the Faculty of Medicine at the University of Duisburg-Essen in Germany. I would like to give you an update on what was reported during the International Headache Congress in Seoul in September.
 

CGRP receptor agonists

Let me start with the treatment of acute migraine attacks. Until recently, we had analgesics, nonsteroidal anti-inflammatory drugs like ibuprofen, ergot alkaloids, and triptans. There are new developments, which are small molecules that are antagonists at the calcitonin gene-related peptide (CGRP) receptor. At the moment, we have three of them: rimegepant 75 mg, ubrogepant 50 mg or 100 mg, and zavegepant (a nasal spray) 10 mg.

These are all effective and superior to placebo. The 2-hour pain-free rate is somewhere between 25% and 30%. They have very few side effects; these include a little bit of nausea, somnolence, nasopharyngitis, and for zavegepant, the nasal spray, taste disturbance. In indirect comparisons, the so-called gepants are about as effective as ibuprofen and aspirin, and they seem to be less effective than sumatriptan 100 mg.

Unfortunately, until now, we have no direct comparison with triptans and we have no data demonstrating whether they are effective in people where triptans do not work. The major shortcoming is the cost in the United States. The cost per tablet or nasal spray is somewhere between $80 and $200. This means we definitely need more studies for these gepants.
 

Migraine prophylaxis

Let me move to the prophylaxis of migraine with drugs. Previously and still, we have all medications like beta-blockers, flunarizine, topiramate, valproic acid, amitriptyline, and candesartan, and for chronic migraine, onabotulinumtoxinA. We have now 5 years’ experience with the monoclonal antibodies against CGRP or the CGRP receptor like eptinezumab, erenumab, fremanezumab, and galcanezumab.

These are all equally effective. They reduce migraine-days between 3 and 7 per month. They are effective both in episodic and chronic migraine, and most importantly, they are effective in people with medication overuse headaches. The 50% responder rates are somewhere between 40% and 60%, and there are no significant differences between the four monoclonal antibodies.

The major advantage is a very good tolerability profile; very few patients terminate treatment because of adverse events. There has been, with one exception, no direct comparison of the monoclonal antibodies with traditional migraine preventive drugs or onabotulinumtoxinA. The only exception is a trial that compared topiramate and erenumab, showing that erenumab was definitely more effective and better tolerated.

At the moment, the recommendation is to use these monoclonal antibodies for 12 months in episodic migraine and 24 months in chronic migraine and then pause. It usually turns out that between 50% and 70% of these patients need to continue the treatment. If they are not working, there is a possibility to switch between the monoclonal antibodies, and the success rate after this is somewhere between 15% and 30%.

Gepants were also developed for the prevention of migraine. Here, we have rimegepant 75 mg every other day or atogepant 60 mg daily. They are effective, but in indirect comparisons, they are less effective than the monoclonal antibodies. At present, we have no comparative trials with monoclonal antibodies or the traditional migraine preventive drugs.

Potential patients are those who have needle phobia or patients who do not respond to monoclonal antibodies. Again, the biggest shortcoming is cost in the United States. The cost per year for migraine prevention or prophylaxis is between $12,000 and $20,000.

Finally, we also had very exciting news. There is a new therapeutic approach via PACAP. PACAP is pituitary adenylate cyclase-activating polypeptide, which has similar biological actions as CGRP but with additional actions. It could very well be that people who do not respond to a monoclonal antibody would respond to a monoclonal antibody against PACAP.

At the congress, the first randomized, placebo-controlled trial with a monoclonal antibody against PACAP was presented. This monoclonal antibody was effective in a population of people in whom prior preventive therapy had failed. A phase 3 study is planned, and most probably the PACAP monoclonal could work in people who do not respond to monoclonal antibodies against CGRP.

Dear colleagues, we have now many choices for the acute treatment of migraine and migraine prophylaxis. We have new kids on the block, and we have to learn more about how to use these drugs, their benefits, and their shortcomings.

He has disclosed the following relevant financial relationships:Received honoraria for participation in clinical trials, contribution to advisory boards or oral presentations from: Abbott; Addex Pharma; Alder; Allergan; Almirall; Amgen; Autonomic Technology; AstraZeneca; Bayer Vital; Berlin Chemie; Bristol-Myers Squibb; Boehringer Ingelheim; Chordate; CoAxia; Corimmun; Covidien; Coherex; CoLucid; Daiichi-Sankyo; D-Pharm; Electrocore; Fresenius; GlaxoSmithKline; Grunenthal; Janssen-Cilag; Labrys Biologics Lilly; La Roche; 3M Medica; MSD; Medtronic; Menarini; MindFrame; Minster; Neuroscore; Neurobiological Technologies; Novartis; Novo Nordisk; Johnson & Johnson; Knoll; Paion; Parke-Davis; Pierre Fabre; Pfizer; Schaper and Brummer; Sanofi-Aventis; Schering-Plough; Servier; Solvay; Syngis; St. Jude; Talecris; Thrombogenics; WebMD Global; Weber and Weber; Wyeth; and Yamanouchi.

Dr. Diener is professor, department of neurology, Stroke Center-Headache Center, University Duisburg-Essen (Germany).

A version of this article appeared on Medscape.com.

This transcript has been edited for clarity.

Dear colleagues, I’m Hans-Christoph Diener from the Faculty of Medicine at the University of Duisburg-Essen in Germany. I would like to give you an update on what was reported during the International Headache Congress in Seoul in September.
 

CGRP receptor agonists

Let me start with the treatment of acute migraine attacks. Until recently, we had analgesics, nonsteroidal anti-inflammatory drugs like ibuprofen, ergot alkaloids, and triptans. There are new developments, which are small molecules that are antagonists at the calcitonin gene-related peptide (CGRP) receptor. At the moment, we have three of them: rimegepant 75 mg, ubrogepant 50 mg or 100 mg, and zavegepant (a nasal spray) 10 mg.

These are all effective and superior to placebo. The 2-hour pain-free rate is somewhere between 25% and 30%. They have very few side effects; these include a little bit of nausea, somnolence, nasopharyngitis, and for zavegepant, the nasal spray, taste disturbance. In indirect comparisons, the so-called gepants are about as effective as ibuprofen and aspirin, and they seem to be less effective than sumatriptan 100 mg.

Unfortunately, until now, we have no direct comparison with triptans and we have no data demonstrating whether they are effective in people where triptans do not work. The major shortcoming is the cost in the United States. The cost per tablet or nasal spray is somewhere between $80 and $200. This means we definitely need more studies for these gepants.
 

Migraine prophylaxis

Let me move to the prophylaxis of migraine with drugs. Previously and still, we have all medications like beta-blockers, flunarizine, topiramate, valproic acid, amitriptyline, and candesartan, and for chronic migraine, onabotulinumtoxinA. We have now 5 years’ experience with the monoclonal antibodies against CGRP or the CGRP receptor like eptinezumab, erenumab, fremanezumab, and galcanezumab.

These are all equally effective. They reduce migraine-days between 3 and 7 per month. They are effective both in episodic and chronic migraine, and most importantly, they are effective in people with medication overuse headaches. The 50% responder rates are somewhere between 40% and 60%, and there are no significant differences between the four monoclonal antibodies.

The major advantage is a very good tolerability profile; very few patients terminate treatment because of adverse events. There has been, with one exception, no direct comparison of the monoclonal antibodies with traditional migraine preventive drugs or onabotulinumtoxinA. The only exception is a trial that compared topiramate and erenumab, showing that erenumab was definitely more effective and better tolerated.

At the moment, the recommendation is to use these monoclonal antibodies for 12 months in episodic migraine and 24 months in chronic migraine and then pause. It usually turns out that between 50% and 70% of these patients need to continue the treatment. If they are not working, there is a possibility to switch between the monoclonal antibodies, and the success rate after this is somewhere between 15% and 30%.

Gepants were also developed for the prevention of migraine. Here, we have rimegepant 75 mg every other day or atogepant 60 mg daily. They are effective, but in indirect comparisons, they are less effective than the monoclonal antibodies. At present, we have no comparative trials with monoclonal antibodies or the traditional migraine preventive drugs.

Potential patients are those who have needle phobia or patients who do not respond to monoclonal antibodies. Again, the biggest shortcoming is cost in the United States. The cost per year for migraine prevention or prophylaxis is between $12,000 and $20,000.

Finally, we also had very exciting news. There is a new therapeutic approach via PACAP. PACAP is pituitary adenylate cyclase-activating polypeptide, which has similar biological actions as CGRP but with additional actions. It could very well be that people who do not respond to a monoclonal antibody would respond to a monoclonal antibody against PACAP.

At the congress, the first randomized, placebo-controlled trial with a monoclonal antibody against PACAP was presented. This monoclonal antibody was effective in a population of people in whom prior preventive therapy had failed. A phase 3 study is planned, and most probably the PACAP monoclonal could work in people who do not respond to monoclonal antibodies against CGRP.

Dear colleagues, we have now many choices for the acute treatment of migraine and migraine prophylaxis. We have new kids on the block, and we have to learn more about how to use these drugs, their benefits, and their shortcomings.

He has disclosed the following relevant financial relationships:Received honoraria for participation in clinical trials, contribution to advisory boards or oral presentations from: Abbott; Addex Pharma; Alder; Allergan; Almirall; Amgen; Autonomic Technology; AstraZeneca; Bayer Vital; Berlin Chemie; Bristol-Myers Squibb; Boehringer Ingelheim; Chordate; CoAxia; Corimmun; Covidien; Coherex; CoLucid; Daiichi-Sankyo; D-Pharm; Electrocore; Fresenius; GlaxoSmithKline; Grunenthal; Janssen-Cilag; Labrys Biologics Lilly; La Roche; 3M Medica; MSD; Medtronic; Menarini; MindFrame; Minster; Neuroscore; Neurobiological Technologies; Novartis; Novo Nordisk; Johnson & Johnson; Knoll; Paion; Parke-Davis; Pierre Fabre; Pfizer; Schaper and Brummer; Sanofi-Aventis; Schering-Plough; Servier; Solvay; Syngis; St. Jude; Talecris; Thrombogenics; WebMD Global; Weber and Weber; Wyeth; and Yamanouchi.

Dr. Diener is professor, department of neurology, Stroke Center-Headache Center, University Duisburg-Essen (Germany).

A version of this article appeared on Medscape.com.