Dithranol Disaster: A Toddler's Skin Emergency & How to Avoid Medication Mishaps
"When psoriasis cream turns into a pediatric crisis: A cautionary tale of accidental exposure, skin reactions, and the vital importance of medication safety in homes with children."
Atopic dermatitis (AD), a common inflammatory skin condition, often presents diagnostic and management challenges, especially in young children. While typically characterized by dry, itchy skin, AD can manifest atypically, complicating both diagnosis and treatment. A recent case highlights the potential dangers lurking in seemingly safe households, emphasizing the critical need for parental vigilance and awareness.
According to a study conducted in Spain, Atopic Dermatitis (AD) presents as idiopathic in 58% of cases, while 42% are associated with sensitization to allergens. In that 42%, 10% were related to food and 26% to airborne allergens. The skin plays an important role in the development of allergic reactions.
Adverse drug reactions are serious public health concerns, leading to increased rates of morbidity and socioeconomic costs. The case of a 2.5-year-old girl with atopic dermatitis reveals how easily medication errors can occur and the importance of careful medication storage.
Dithranol Requires Careful Application
NICE says a healthcare professional may offer short-contact dithranol ointment or cream for some forms of localized psoriasis when other treatments have not been successful. The guidance emphasizes support to help patients apply it correctly, or treatment in a specialist setting. The supplied NICE material describes when this treatment may be offered and how it should be supported; it does not provide statistics on its use or impact.
Treatment Evidence and Safety Questions
A study of targeted systemic immune-modulating drugs for atopic dermatitis reports high efficacy in randomized trials, while noting that trials with limited numbers of participants leave safety questions. The 2023 American Academy of Allergy, Asthma & Immunology guideline says it provides evidence-based recommendations for managing atopic dermatitis in infants, children, and adults. It also says risk considerations should include observed drug safety data and class-wide theoretical concerns and FDA boxed warnings for JAK inhibitors; oral JAK inhibitors are contraindicated in pregnancy and breastfeeding.
Accidental Exposure: When Psoriasis Cream Becomes a Hazard
A seemingly ordinary day took a concerning turn for a 2.5-year-old girl with atopic dermatitis. After a history of atopic dermatitis since the age of 2 months, managed with a dairy-free diet, and treatment, she developed severe inflammatory skin lesions accompanied by intense itching. The doctors were initially puzzled. The girl's parents were observant, stating the recent flare-ups of AD, had no connection to foods, consumption or other external factors.
- What is Dithranol? Dithranol, derived from the araroba tree, has long been a treatment for psoriasis.
- Concentrations: Pediatric use requires lower concentrations (0.016%-0.625%) compared to adult applications (0.1% to 5%). The presented case used 2% Dithranol ointment.
- Why is it risky? Adverse effects include burning, irritation, and allergic contact dermatitis. Dithranol's irritant potential complicates allergy testing, potentially exceeding hypersensitivity detection thresholds.
Reviews of Emerging Atopic Dermatitis Therapies
A review evaluates the efficacy and safety of novel and emerging topical and systemic therapies for atopic dermatitis. It covers both pediatric and adult populations. Its stated emphasis is on recent advancements and future directions.
Application Risks and Evidence Limits
In a reported chemical burn case involving dithranol with salicylic acid, the authors suspected the patient may have unknowingly touched her neck, face, or upper torso and failed to rinse those areas. Separately, a systematic review of topical treatments for plaque psoriasis found no significant differences in tolerability or steroid atrophy, but noted that the data were limited. These findings describe a suspected application mishap and limits in comparative evidence, not a measure of how often such events occur.
Different Treatments, Different Evidence
In a childhood psoriasis study of short-contact dithranol therapy, mild adverse skin reactions occurred in 20% of patients, and only one patient had to stop treatment. A review of systemic treatments for atopic dermatitis reports that dupilumab, tralokinumab, lebrikizumab, and oral JAK inhibitors have been shown to be safe and efficacious. That review also reports that high-dose cyclosporine and dupilumab were more effective than methotrexate and azathioprine in improving clinical signs of atopic dermatitis; these findings concern different conditions and are not a direct comparison with dithranol.
Protecting Children: A Guide to Medication Safety at Home
This incident emphasizes the necessity of diligent medication management and storage. Ensure all medications are stored out of reach of children, clearly labeled, and that family members are aware of potential risks associated with each medication. It also underlines the importance of disclosing to physicians about the accidental exposure in children. By implementing these safeguards, parents and caregivers can create a safer environment and prevent accidental exposures. Being informed, communicative, and proactive is key to protecting children from medication-related harm.
Patient-Reported Improvements
A case-based discussion presents a 36-year-old man with a history of atopic dermatitis and highlights limitations of over-the-counter corticosteroids while discussing other treatment options. In a separate report, patients starting dupilumab reported rapid improvements in skin lesions, itch, sleep, and overall quality of life, with scores moving from severe or very large effects to mild or small effects. Those reported improvements were sustained for up to one year, and the report said safety data were consistent with previous studies.