Children's atopic dermatitis: systemic treatment responses held across skin colour

Design

International observational registry, 4-year results

Population

500 children under 12 with moderate-to-severe atopic dermatitis (314 White, 186 non-White)

Primary outcome

Change in EASI and patient-reported outcomes by skin colour

Effect

EASI improvement, non-White: dupilumab 13.6, methotrexate 8.2, ciclosporin 9.2 points

PEDISTAD is an international observational registry of children with moderate-to-severe atopic dermatitis. This analysis compared 314 White and 186 non-White children under 12 on systemic treatment over four years.

Eczema Area and Severity Index scores improved with all three treatments. 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, 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. Exposure-adjusted adverse event rates were lower in non-White children across all three drugs.

The practical point is that response to these drugs did not differ in a way that should change choice by skin colour. The comparison between drugs is observational — children were not randomised and sicker children may have received different drugs — so it does not show dupilumab is superior. In India, cost and access usually decide between dupilumab and methotrexate or ciclosporin more than any of this.

• Choose systemic treatment for childhood eczema on severity, comorbidity and access, not on skin colour.
• Use validated severity scores in darker skin, where erythema is harder to judge, to track response.
• Expect itch to improve less with ciclosporin than with dupilumab.
• Monitor methotrexate and ciclosporin as usual; adverse event rates were not higher in non-White children.

Why it matters

It addresses a concern that trial data from mostly White children may not apply to others.

Don't overread it

Treatment was not randomised; the registry cannot establish one drug as more effective than another.

The statistics, in plain English

These are average point improvements on a severity score, observed in a registry rather than a trial. Differences between the drugs may reflect who received which drug rather than the drugs themselves.

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