Dupilumab led methotrexate and ciclosporin in children with severe eczema, whatever their skin colour

Design

International observational registry

Population

500 children under 12 with moderate-to-severe atopic dermatitis (186 non-White)

Primary outcome

Change in EASI, itch and quality of life on systemic treatment

Effect

EASI improved 13.6 (dupilumab), 8.2 (methotrexate), 9.2 (ciclosporin) points in non-White children

PEDISTAD is an international observational registry of children under 12 with moderate-to-severe atopic dermatitis. This four-year analysis compared outcomes of systemic treatment in 314 White and 186 non-White children; the non-White group included Asian, Black and multiracial children.

Eczema Area and Severity Index scores improved with every treatment. In non-White children the mean improvement was 13.6 points with dupilumab, 8.2 with methotrexate and 9.2 with ciclosporin; in White children it was 14.2, 10.1 and 4.5. Itch and quality of life improved most with dupilumab in both groups, and ciclosporin did least for itch. Adverse event rates were not higher in non-White children.

The finding that response did not differ by skin colour is reassuring for Indian practice, where trial populations have often been mostly White. Cost and access, however, decide much of the choice in India, and methotrexate remains a reasonable and affordable systemic option.

• Expect systemic treatments for severe childhood eczema to work in children with darker skin as they do in White children.
• Weigh cost and access alongside effect size when choosing a systemic agent.
• Use methotrexate as an affordable systemic option, with blood monitoring and folic acid.
• Score severity at baseline and follow-up so response can be judged objectively.

Why it matters

It addresses a gap in evidence for children with darker skin, who were under-represented in the trials.

Don't overread it

This is registry data without randomisation; children were not assigned treatments at random, so the drug comparisons may be confounded.

The statistics, in plain English

These are average point reductions on a 72-point severity scale, observed rather than randomised, and with no confidence intervals given here. Differences between drugs may partly reflect which children were offered which treatment.

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