FCPS Paediatrics TOACS · Interactive Station

✅ Candidate's answer:
• Assess adherence: Is the patient using topical corticosteroids correctly (frequency, amount, application technique)? Are emollients used daily?
• Identify and eliminate triggers:
- Irritants: Soaps, detergents, wool, rough fabrics.
- Allergens: Food allergens (milk, egg, peanut, soy, wheat – especially if severe AD). Consider skin prick testing or specific IgE.
- Aeroallergens: Dust mites, pet dander, pollen (consider allergy testing).
- Infections: Staphylococcus aureus colonization/impetiginization (consider antibiotics if infected), eczema herpeticum (HSV) – ensure none.
- Contact dermatitis to topical preparations (lanolin, parabens, preservatives).
• Optimize topical therapy: Use the right potency for the right area (face/groin – low potency; trunk/extremities – medium-high potency). Use “soak and smear” technique (bath + emollient + steroid).
• This patient has already failed potent topical steroids and tacrolimus, poor adherence to tacrolimus due to burning. Step-up therapy is indicated.

✅ Candidate's answer:
• Mechanism: Inhibit calcineurin → block T-cell activation and cytokine release (IL-2, IL-4, IL-5, IL-13). Non-steroidal anti-inflammatory.
• Indications:
- Second-line therapy for moderate-to-severe AD when topical corticosteroids are ineffective, not tolerated, or for sensitive areas (face, neck, intertriginous areas) to avoid steroid-induced atrophy.
- Approved for children ≥2 years (pimecrolimus cream 1% for mild-to-moderate AD; tacrolimus ointment 0.03% and 0.1% for moderate-to-severe AD).
• Black box warning (FDA): Potential increased risk of lymphoma and skin cancer. However, long-term studies have not confirmed this risk in children. The warning is based on animal studies and rare case reports. Benefits may outweigh risks in severe AD.
• Side effects: Burning, stinging, pruritus (most common, often resolves within 1 week). This patient experienced burning and poor adherence – try lower concentration (0.03% tacrolimus) or consider alternative therapy.
• Do not use in immunocompromised children or those with active cutaneous infection.

✅ Candidate's answer:
• Role: Phototherapy is an effective second-line or third-line treatment for moderate-to-severe AD that is refractory to topical therapy. It reduces T-cell infiltration, decreases inflammatory cytokines, and improves skin barrier.
• Most common type: Narrow-band ultraviolet B (NB-UVB, 311-313 nm) – preferred due to efficacy and safety profile. Also broadband UVB and UVA1 are used.
• Protocol: Usually 2-3 sessions per week for 12-24 weeks. Maintenance therapy may be needed.
• Side effects:
- Short-term: Erythema (sunburn), pruritus, dryness.
- Long-term: Photoaging, increased risk of skin cancer (with high cumulative doses; NB-UVB is lower risk than PUVA).
• Contraindications: Photosensitivity disorders, history of skin cancer, immunosuppression.
• This patient (7 years old) may be a candidate for NB-UVB if available and if family can commit to frequent visits.

✅ Candidate's answer:
• Role: Cyclosporine is a first-line systemic immunosuppressant for severe, refractory AD in children (off-label). It is highly effective for rapid control (onset within 2-4 weeks). Used as a short-term (3-6 months) bridging therapy.
• Dose: 2.5-5 mg/kg/day orally (divided twice daily). Start at lower dose (2.5-3 mg/kg/day) and titrate based on response and renal function.
• Monitoring:
- Baseline and every 2-4 weeks: BP, serum creatinine, BUN, electrolytes, LFTs.
- Monitor for hypertension, nephrotoxicity, hyperkalemia, hypomagnesemia.
- Avoid nephrotoxic drugs (NSAIDs, ACE inhibitors, aminoglycosides).
• Side effects: Hypertension (30-50%), nephrotoxicity, headache, tremor, hirsutism, gingival hyperplasia, GI upset, immunosuppression (risk of infection).
• Duration: Usually 3-6 months, then taper. Rebound flares may occur after discontinuation.
• This patient is a candidate for cyclosporine if NB-UVB is not available or if rapid control is needed.

✅ Candidate's answer:
• Role: Methotrexate is a second-line systemic immunosuppressant for severe AD (off-label). It is used when cyclosporine is not tolerated or contraindicated. Onset of action is slower (6-12 weeks).
• Dose: 0.2-0.4 mg/kg/week orally or subcutaneously (max 25 mg/week). Folic acid supplementation (1 mg/day) to reduce side effects.
• Monitoring (critical):
- Baseline: CBC, CMP, LFTs, BUN/creatinine, chest X-ray (exclude TB), pregnancy test (females).
- Every 1-3 months: CBC, LFTs, albumin, creatinine.
- Monitor for hepatotoxicity (elevated LFTs, cirrhosis – cumulative dose-related).
- Pulmonary toxicity (pneumonitis – rare but serious).
- Bone marrow suppression (leukopenia, thrombocytopenia, anemia).
• Contraindications: Pregnancy (teratogenic), significant liver disease, renal impairment, alcohol use, immunodeficiency.
• This patient may be considered for methotrexate if cyclosporine fails or if long-term therapy is needed.

✅ Candidate's answer:
• Mycophenolate mofetil (MMF):
- Inhibits inosine monophosphate dehydrogenase → suppresses lymphocyte proliferation.
- Dose: 20-40 mg/kg/day divided BID (max 2 g/day).
- Monitoring: CBC, LFTs, renal function monthly.
- Side effects: GI upset (diarrhea, nausea), leukopenia, increased risk of infection.
- Used off-label for severe AD, often when other agents fail or cause toxicity.
• Azathioprine:
- Purine analog, inhibits DNA synthesis in lymphocytes.
- Dose: 1-3 mg/kg/day.
- Requires TPMT (thiopurine methyltransferase) testing before use to identify patients at risk for severe myelosuppression.
- Monitoring: CBC, LFTs, renal function.
- Side effects: Myelosuppression, hepatotoxicity, pancreatitis, nausea.
- Used less commonly in children due to side effect profile.
• Both are third-line options after cyclosporine and methotrexate. Refer to dermatologist for initiation and monitoring.

✅ Candidate's answer:
• Dupilumab (Dupixent): A fully human monoclonal antibody that blocks the IL-4 receptor α subunit, inhibiting both IL-4 and IL-13 signaling (key type 2 cytokines in AD).
• FDA approval: Children ≥6 years with moderate-to-severe AD not adequately controlled with topical therapy.
• Dose (subcutaneous injection):
- 15-30 kg: 300 mg every 4 weeks (after initial loading dose).
- 30-60 kg: 200 mg every 2 weeks.
- >60 kg: 300 mg every 2 weeks.
- Loading dose: 400-600 mg initially.
• Efficacy: Rapid improvement in pruritus and EASI (Eczema Area and Severity Index) scores within 2-4 weeks. Sustained improvement.
• Side effects: Injection site reactions, conjunctivitis (common), nasopharyngitis, headache. Less risk of immunosuppression than systemic steroids.
• This patient (7 years old, severe AD, failure of topical therapy) is an excellent candidate for dupilumab.

✅ Candidate's answer:
• JAK inhibitors (Janus kinase inhibitors) block cytokine signaling pathways (JAK-STAT) involved in AD pathogenesis (IL-4, IL-13, IL-31, etc.).
• Topical JAK inhibitors:
- Ruxolitinib 1.5% cream (Opzelura): Approved for mild-to-moderate AD in children ≥12 years. Not yet approved for younger children.
- Delgocitinib ointment: Approved in Japan for children ≥2 years, not in the US.
• Oral JAK inhibitors (systemic):
- Abrocitinib, upadacitinib: Approved for adults with moderate-to-severe AD. Pediatric trials ongoing. Not FDA-approved for children <12 years.
- Baricitinib: Approved for adults.
• Side effects of oral JAK inhibitors: Increased risk of infection (herpes zoster), thrombosis, lipid elevations, GI perforation (rare). Require lab monitoring.
• This patient (7 years) is not a candidate for current JAK inhibitors (age <12). Dupilumab is the preferred biologic.

✅ Candidate's answer:
• Yes, evaluation for food allergy is indicated in children with moderate-to-severe AD who are refractory to standard therapy, especially if they have early-onset, severe AD.
• Most common food allergens: Cow's milk, egg, peanut, soy, wheat, tree nuts, fish, shellfish.
• Prevalence: Up to 30-40% of children with moderate-to-severe AD have IgE-mediated food allergy that may exacerbate eczema.
• Diagnostic approach:
- Skin prick testing or specific IgE (blood test) for suspected foods based on history.
- If positive, consider elimination diet for 2-4 weeks, followed by oral food challenge to confirm.
- Do NOT perform empiric elimination diets without testing (risk of nutritional deficiencies).
• Important: Even if food allergy is identified, removal of the food may not completely clear AD, but it can improve control and reduce the need for topical steroids.
- This patient should have food allergy testing before proceeding with systemic therapy.

✅ Candidate's answer:
• Before starting systemic immunosuppressants (cyclosporine, methotrexate, dupilumab), screen for:
1️⃣ Tuberculosis (TB): Chest X-ray and interferon-gamma release assay (IGRA) or tuberculin skin test (TST). Treat latent TB before starting immunosuppression.
2️⃣ Hepatitis B and C: HBsAg, HBcAb, HBsAb; HCV antibody.
3️⃣ HIV: Screen if risk factors present.
4️⃣ Varicella-zoster virus (VZV): Check VZV IgG. If non-immune, vaccinate before starting immunosuppression (at least 4 weeks prior).
5️⃣ Herpes simplex virus (HSV): If history of recurrent HSV, consider prophylaxis (acyclovir) during immunosuppression.
6️⃣ Staphylococcus aureus colonization: Not routinely screened, but treat active infection before starting systemic therapy.
• This patient: Ensure up-to-date on immunizations (including varicella). Screen for TB, HBV, HCV before starting systemic therapy.

✅ Candidate's answer:
• Wet wrap therapy: Application of topical corticosteroid and emollient followed by a damp (wet) inner layer and a dry outer layer of tubular bandages or pajamas. Used for severe, refractory AD.
• Indications: Acute flares of severe AD, especially in hospitalized patients or those who have failed outpatient therapy. Can be used for short-term (3-14 days) to rapidly control inflammation.
• Procedure:
- Soak in lukewarm water for 15-20 minutes.
- Apply emollient to entire body, then topical corticosteroid to affected areas.
- Apply wet wrap (dampened tubular gauze) followed by dry wrap.
- Leave on for 6-12 hours (usually overnight).
• Risks:
- Increased systemic absorption of topical corticosteroids (risk of adrenal suppression, Cushing syndrome, growth suppression).
- Skin maceration, folliculitis, secondary bacterial infection.
- Discomfort, poor adherence.
• Must be supervised by a physician and used for short durations only.
- This patient may benefit from a short course of wet wrap therapy as a bridge to systemic therapy.

✅ Candidate's answer:
• Refer to dermatologist (or allergist with expertise in AD) if:
1️⃣ Severe AD (BSA >30%, EASI >20, poor quality of life).
2️⃣ Refractory to optimal topical therapy (potent corticosteroids, calcineurin inhibitors, emollients).
3️⃣ Need for phototherapy or systemic immunosuppressants (cyclosporine, methotrexate, dupilumab).
4️⃣ Diagnostic uncertainty – rule out other dermatoses (psoriasis, contact dermatitis, cutaneous T-cell lymphoma).
5️⃣ Recurrent or severe infections (eczema herpeticum, recurrent staphylococcal abscesses).
6️⃣ Evaluation for contact allergy (patch testing).
7️⃣ Need for allergen immunotherapy if aeroallergens are significant triggers.
• This patient (severe, refractory, potential candidate for dupilumab or cyclosporine) should be referred to a dermatologist or pediatric allergist with AD expertise.

✅ Candidate's structured answer:
• “I understand your frustration. You have done everything right – consistent creams, moisturizers, avoiding triggers. Your son has severe eczema, and sometimes topical treatments alone are not enough.”
• “The good news is that there are several additional treatments we can try now. You mentioned the 'shots' – you are likely referring to a medication called dupilumab (Dupixent). It is a biologic injection given under the skin every 2-4 weeks. It blocks specific inflammatory signals in the body that cause eczema. It is approved for children 6 years and older with moderate-to-severe eczema.”
• “Dupilumab is very effective – most children experience dramatic improvement in itching and skin clearing within 4-8 weeks. It is generally safe, but side effects can include injection site reactions and eye redness (conjunctivitis).”
• “Before we start any systemic medication, we need to do some blood tests to make sure your son is healthy and to screen for infections like tuberculosis and hepatitis.”
• “Other options include light therapy (phototherapy) – like a special UV light booth – or oral medications like cyclosporine or methotrexate. These work well but have more side effects and require regular blood monitoring.”
• “I recommend we refer you to a dermatologist who specializes in pediatric eczema to discuss these options in detail. Together, we will find a treatment that works for your son. You are not alone.”

✅ Candidate's answer:
• Ongoing monitoring:
- Regular follow-up every 1-3 months to assess disease severity, treatment response, and side effects.
- Use validated tools: EASI (Eczema Area and Severity Index), SCORAD, POEM (Patient-Oriented Eczema Measure), and quality-of-life questionnaires.
- Monitor growth (height, weight) in children on systemic therapy.
• Disease activity: Even on systemic therapy, continue optimal topical therapy (emollients, proactive weekend use of topical corticosteroids or calcineurin inhibitors on previously affected areas to prevent flares).
• Infection prevention: Keep up-to-date with immunizations (including influenza, pneumococcal, varicella if not yet infected). Educate about signs of eczema herpeticum and bacterial superinfection.
• Triggers: Continue avoidance of identified triggers (allergens, irritants).
• Plan for treatment withdrawal: Systemic therapy is often continued for 6-12 months, then tapered if disease is well-controlled. Dupilumab is often continued long-term.
• Psychosocial support: Address sleep disturbance, school absenteeism, family stress, and mental health (anxiety, depression).
- This patient needs a long-term partnership with a specialist and a comprehensive care plan.