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[00:04]
Host/Interviewer
Thrilled to have Dr. Sheila Fallon Friedlander here with us. So for any of our listeners who don't know Dr. Fallon Friedlander, she is a pediatric dermatologist extraordinaire. You're at UC San Diego.
[00:19]
Dr. Sheila Fallon Friedlander
I'm emeritus at ucsd and I'm on staff at Scripps.
[00:23]
Host/Interviewer
Okay, so you have been peds derming for too long. When did you start? When did you.
[00:32]
Dr. Sheila Fallon Friedlander
Do you really want to know this?
[00:34]
Host/Interviewer
I want to know when did you start pedsderming?
[00:36]
Dr. Sheila Fallon Friedlander
No, I started out in pediatrics because I remember being in the emergency room where I trained and seeing what the PDR was like compared to the adult er. So you walk through the doors to the adult ER and the smell just overwhelms you. Of the diabetics and everybody, you know, you're on the wrong edge of the curve. You know, you're in the wrong spot. And I thought, well, in peds we could probably make things better. So I started out in peds and I loved it, but I was sort of OCD and I there night and day. And, you know, when I was a chief, I didn't come home. But I always realized, too, I loved infections. So I did two years of infectious diseases and that. And then while I was doing that, I realized, God, we're cross consulting and all the derm consults, only they get to read more. Idaho fellows are tortured. I'm just going to tell you right now, it's a wonderful field. But I realized if I did derm, I could read more. And I might occasionally see my husband. So that's my story. And then the last part of my training was in Durham at ucla. And then Larry Eichenfeld needs someone to help him at UCSD. And I was there for 30 some years. Okay, yeah, about that.
[01:54]
Host/Interviewer
30 some years.
[01:55]
Dr. Sheila Fallon Friedlander
No, I can't be that old. Maybe.
[01:57]
Guest/Colleague
Yeah, we started at 10.
[01:59]
Dr. Sheila Fallon Friedlander
Yes, yes, yes. I was precocious. I was precocious.
[02:02]
Host/Interviewer
So to me, the most exciting. And I'm a dermatitis person, obviously. So the most exciting thing has been that we now have these three. We had no good topical options for kids, right? We had topical steroids, which parents are all afraid of. We had TCIs, which, you know, tacrolimus burned in so many kids. Pomecrolimus just didn't work all that great. And now we've suddenly got. And then we got. We had Eucrisa, which burns. And then now we've got three great drugs that are very well tolerated, very effective, the whole thing. But I'm not Pedsderm. How do you pick? Like, so you're like, when do you use Opzelura? When do you use Zoriv? When do you use.
[02:48]
Dr. Sheila Fallon Friedlander
Yeah, okay.
[02:49]
Host/Interviewer
And we're allowed to use brand names.
[02:51]
Dr. Sheila Fallon Friedlander
You may want to cut this out later. But it's so funny when you do the lit. We do this every year together. These literate. And I was thinking this year, what's the most important thing for this audience to go home with? I must be getting old. And I'm, you know, anyway, so I'm thinking about this not what I will look good or smart. And. And I decided the drugs and the use of the drugs, the new drugs and the information we have about peds atopic derm. So I proceeded to talk about the three drugs during my lit review and I got a dressing down.
[03:27]
Host/Interviewer
You got in trouble from the two bosses.
[03:32]
Dr. Sheila Fallon Friedlander
I was supposed to be doing a lit review, not drugs. I said the drugs are in the lit review. But, you know, new drugs comes right out of new drugs. I'm so glad you've asked me to talk about this because it makes me feel better. I think it is the most. And I rarely talk just about drugs in the literature, but I thought this is such a move forward for our patients. Well, dupixent, of course.
[03:55]
Host/Interviewer
Yeah, we're talking about dupixent.
[03:57]
Dr. Sheila Fallon Friedlander
Major, major, major.
[03:58]
Host/Interviewer
Yes, we're gonna get to that.
[03:59]
Dr. Sheila Fallon Friedlander
But in the last year or two, we have so many choices. As you said, it used to be. Well, my husband would say, if it's wet, dry it. If it's dry, wet it. And if that doesn't work, throw an ointment on it. That's sort of eczema too. But anyway, so. So we used to have topical steroids. The calcineurin inhibitors were a big move forward, but there's so many problems. The black box scared everybody to death. And the stinging, the stinging went along with them. And they're not as strong as the topical steroids. Come on, let's face it. So then Chrisaboro came along and I was so excited, mostly because it's down to three months to have drug FDA approved. Of course, the insurance companies might not have happy, but I was very happy. I had something FDA approved and then I used it. And in some cases it is helpful, especially for the face, you know, when you. What are your options? Steroids or the calcineurin inhibitors. But in most cases, it wasn't all that strong. However, it's all I had, so I used a lot of it. And it's safe like the families loved. Oh, it's boron based. Oh, it's not the evil steroid. Yes. This is wonderful. Okay, so. So then all of a sudden we had Roflumilast, we had tipirinoff. I guess that Ruxolitinib has been out there sort of sitting around making sense. We should have used it. But it's just in the last year or two that people have really started in my world, using in Pete's cases. So where do we stand about which drugs are the best? Well, what do we want to talk about? Do we want to talk about fear? So, you know, human fear, practitioner fear. Ruxolitanum. People are still a little concerned. It's a JAK inhibitor. You very sophisticated people will tell me there's nothing to worry about with jaks. But the fact of the matter is,
[05:59]
Host/Interviewer
talking to a parent about a boxed warning is not easy.
[06:01]
Dr. Sheila Fallon Friedlander
Exactly. And the pediatricians, what you need to remember is your pediatric practitioners are taught not to use anything new for at least five years. Let all the mistakes be made in the adults. Okay, so. So it was something with a black box on it. And so Ruxlitinib, even, I think, and I'm just gonna say empirically, it is so great. Rex Litinib.
[06:25]
Host/Interviewer
Yeah, it works. Really, really works.
[06:28]
Dr. Sheila Fallon Friedlander
It really works. But there are a couple of things that work against us. One bid versus qd. I mean, I love the fact that the other two are QD approved daily rather than twice a day. It makes a difference in a two career family. Let's just say they're just hanging in there. They're trying their kids up in the morning, they're trying to get them out. If you only have to put something on once a day, you could sort of determine the moment you have. So the fact that ruxolitinib is twice a day. So twice the work, if you're going to follow the advice. But the major concern, and you could say it's all hypothetical, but I still think the major concern is the issue of absorption and what the absorption can do.
[07:12]
Host/Interviewer
Yeah. Because and for our listeners who didn't, maybe not everybody remembers this from residency kids. There's two things. There's the body to surface area to volume ratio. So they have relatively more body surface,
[07:28]
Dr. Sheila Fallon Friedlander
body surface area, body surface area volume. It's like we have all these crevices in the babies. It's a way of looking at it. So you can put a tremendous amount on for a very little baseline weight. Yes.
[07:42]
Host/Interviewer
And it's easy to cover with an adult, you can't treat 20% of their body with a cream. With a baby, it's not that hard to treat 100%. Just put it all over and it's a really important. You really then can get significant levels.
[07:54]
Dr. Sheila Fallon Friedlander
And that plays an important role because in approving this drug, they said body surface area ratio less than 20%. So they're out of the gate saying, don't put it on more than 20%. And then the other part they now have is or one 60 gram tube every two weeks, you're allowed to prescribe for the younger kids. So, okay, when you're busy trying to explain to a family, oh, this is perfectly safe, but don't you put more
[08:21]
Guest/Colleague
than a tube into.
[08:22]
Dr. Sheila Fallon Friedlander
Yeah, yeah. So if it says that, I think you have families concern. Having said that, I understand it's a theory. Oh, and then there was a recent publication where they looked at absorption in kids and it is absorbed. But in the publication, which is not getting much press, they made great effort to say, but it was absorbed below the myelosuppressive dose. Did you see that?
[08:48]
Guest/Colleague
I did.
[08:48]
Dr. Sheila Fallon Friedlander
And like nobody.
[08:49]
Guest/Colleague
It was the JAD paper. Was that the one in jad?
[08:51]
Dr. Sheila Fallon Friedlander
I'm pretty sure it was jad, but nobody's talking about it, which, I mean, it's so what I'm saying.
[08:56]
Host/Interviewer
And the point is the myelosuppression level is lower than. Is much higher than the immunosuppression level. Right. You can get immunosuppression without having myelosuppression.
[09:06]
Dr. Sheila Fallon Friedlander
Having said all of that, we will probably find out that it's totally safe, that it's totally safe. But when you're dealing with pediatric patients, pediatric doctors and pediatricians, they're going to have some concern and I think they're going to want to give it a little more time unless there's nothing else out there. So now to me, Opzolar works great. I love it. In the older kids, where I'm not using it in a lot of areas, I think it's a wonderful drug. In the younger kids, there are a lot of other issues. So would I use it? Yes, but not first line. So now we have two others. And to pin her off, Vitama. Initially I was like, I don't understand how it works. So maybe I'm not going to, you know, the aryl hydrocarbon receptor. There's no way I could talk about this as a meeting. I'm sure it's clear for some, but not for me.
[10:01]
Host/Interviewer
No, we don't Really, I mean, we know some of the stuff it does, but we don't really. That is a really complicated pathway. Like, there are so many different things. So it is a ligand. Its activities are ligand dependent. So depending what binds to AHR and activates it, it does different things. Right. In different states. So it's. It. While I feel like, oh, I understand. Like, it's just not a well understood pathway in general, it seems to work
[10:27]
Guest/Colleague
in multiple different, like cell types and disease states. And so. Yeah.
[10:32]
Dr. Sheila Fallon Friedlander
Which then can sort of throw you off because we want things to be as specific as they can be. But anyway, you're making me feel better having explained that. It's hard to explain. So initially I. Well, I don't understand how it works. But then I decided, hey, I'm going to try it. Look, it's approved all the way down. I've had great results.
[10:55]
Host/Interviewer
So I did the trials for both psoriasis and ad and when we started to do the AD trial, I was like, oh, man, this is good. Because I was expecting to be kind of slow. It's a good psoriasis drug. It is a really good atopic derm drug. It is shocking to me how fast it works.
[11:14]
Dr. Sheila Fallon Friedlander
Agreed.
[11:14]
Host/Interviewer
It's crazy.
[11:15]
Dr. Sheila Fallon Friedlander
Kids who were having trouble with just about everything and I'm like, just hold because I had some samples in the office or whatever. It's really a good drug and it's daily now. What problems? I've had some folliculitis with it. I've had some people complain, but it's very exciting to me how well it works.
[11:34]
Host/Interviewer
And it's got the perfect. Put it on once a day, anywhere
[11:36]
Dr. Sheila Fallon Friedlander
you got eczema every day. Qd. Qd. When you hear that re, eczema goes
[11:40]
Host/Interviewer
away, stop putting it on, comes back, start putting it on again.
[11:43]
Guest/Colleague
So how do you think it compares to Zerve then?
[11:46]
Dr. Sheila Fallon Friedlander
We're getting to Zariv. It's next on our list. Zarive. Sometimes I've had some patients who loved it. I just got a call today from a mother who said, oh, you made me taper into. From my steroids into Zarev. And it's doing nothing. So, you know, it's only an n of 1. I've had other patients who seem to really like it. But the confusing part of Zariv initially was the three concentrations, which. And so if you're trying to talk to people about it, well, why are you giving me this one versus that? And again, back to Matt's point. It's all about Very sophisticated, intelligent people designing their trials and realizing that absorption could be an issue. Where do we want these 80 drugs to be used? Well, most AD people are little kids. You know, the incidence is much higher in young kids. So I think the company looked at it and said, we're going to make a concentration that's low. Well, first they showed, to my understanding, that it worked at various.
[12:51]
Host/Interviewer
And the three concentrate, there's.05, 0.15 and 0.3.
[12:56]
Dr. Sheila Fallon Friedlander
Yeah.
[12:57]
Host/Interviewer
Is that right?
[12:57]
Dr. Sheila Fallon Friedlander
And the ones. The foam too?
[12:59]
Host/Interviewer
Yeah, yeah. Then there's the foam and there's 0.3 foam and a 0.3 cream. And then I think a 0.15 cream. And a 0.05 cream.
[13:06]
Dr. Sheila Fallon Friedlander
Yeah. So the point to them, I think, was let's go with the lowest concentration. That will work. And guess what? The lowest concentration does work. So in explaining that to families, and again, you could say, what's my big hold up? You need to be able to explain things in a way that will make sense. So now that I've realized, number one, I think Zuri works well. I also love it for Septerma. I can sort of throw it on anything. I was thinking about maybe the water supply. Do you think we could throw it in? But I think that it works for a lot of us.
[13:39]
Host/Interviewer
They should come up with a powder you put in the bath, right? That's a very good idea.
[13:44]
Dr. Sheila Fallon Friedlander
That's right.
[13:45]
Host/Interviewer
A powder you put in the bath.
[13:47]
Dr. Sheila Fallon Friedlander
Yeah. So first of all, families have to understand because then when you say it's a lower concentration. Oh, is it dangerous then? And you know what I tell families, as a pediatrician, I was working with PD4 inhibitors 30 years ago because all the asthma meds. Theophylline. Yeah. So I was using theophylline all the time. So I understood phosphodiesterase inhibitors. And we had so much experience with it that I realized systemically, even, of course, there's side effects. But a lot of experience with that class so that I find reassuring. And sometimes if I'm really crazy, I'll try to explain how it works. And we want more cyclic amp around, but most days I have too much sense to do that. So I think that both of those drugs, all three of them, have a role in my hands. Very conservative. I don't know how well you know me, but I'm pretty conservative. You know, I'm not going to take a risk. Dermatologist, you guys are all, save the baby. So, anyway, in my experience, initially I was going to go Roflumulast oreve I'm going to use that and I do like it. But I have been so impressed with my results with vitamin and I didn't know whether it's just me, but you're
[15:02]
Host/Interviewer
telling you did the trials and it's, you know, the way that I think about it. And so because in adults, the way I think about it. So it sounds like the same thing goes in kids, but it's even more important in kids. I think of Opzelura as the most effective but the most safety concerns. I think of Zoriv as the fewest safety concerns but the least effective and Vatama almost as the Goldilocks. And do you.
[15:27]
Dr. Sheila Fallon Friedlander
You're pretty good at summarizing things, by the way.
[15:30]
Host/Interviewer
Thank you.
[15:30]
Dr. Sheila Fallon Friedlander
That's what I was trying to say.
[15:32]
Host/Interviewer
Do you recommend one to families or do you give them like, okay, here are these three creams we could pick from. This one works the best, but it's got some safety concerns. This one's the safest, but it doesn't work as well. Or do you tell people this is the one that I would use if it was my kid.
[15:50]
Dr. Sheila Fallon Friedlander
First of all, it depends on how old the kid is and what the experience is. So if I have had a kid with bad atopic dermatitis, a pre adolescent little bit older and maybe he needs a little boost or a kid on dupy and I want a little. And so maybe this is again the rules, but I will use Apsalura on a kid who's doing really pretty well on Doopie. But at week three he seems to start to run into trouble. So that's my audience for Opsolura out of the gate.
[16:19]
Host/Interviewer
By the way, I was confused for a moment there because I was like doopies every two weeks, but then in kids and some of the kids it's every four.
[16:25]
Dr. Sheila Fallon Friedlander
Okay, okay, sorry about that. So it depends. So for that group I use a lot of Apsalur. Do you want to know the real truth? What's around, what samples I have and what can I get through insurance?
[16:40]
Guest/Colleague
Insurance drugs.
[16:41]
Dr. Sheila Fallon Friedlander
Can you prescribe like two of those for the same people or is that like insurance?
[16:49]
Host/Interviewer
I have been able to do it if I prescribe for one for Seb Derm and one for ad or if I do one for psoriasis and one for AD sometimes I've been able to get that.
[17:02]
Dr. Sheila Fallon Friedlander
But do you have them use it on similar body surfaces or not?
[17:05]
Host/Interviewer
Yes. And so I'll do. Right. I'll do, you know, Vitamma once a day and it's for somebody who's not doing well and I still want to stay topical, we'll do Vitama once a day and Zoriv once a day or, you know, something like that.
[17:17]
Dr. Sheila Fallon Friedlander
So what's your experience doing this clinical trial sorts?
[17:21]
Host/Interviewer
I think it works better. I think doing that. I think the different mechanisms of action to Panera.
[17:26]
Dr. Sheila Fallon Friedlander
I think we know opzelure is the best. We are. I mean, we're in agreement. I think that's.
[17:32]
Host/Interviewer
I think it's the most effective.
[17:33]
Dr. Sheila Fallon Friedlander
Yeah.
[17:33]
Host/Interviewer
And it's the fastest. All right, let's change gears though. So.
[17:36]
Guest/Colleague
But I want to ask one last question. Do you guys ever combine these with topical steroids? Like if you said, you know, look, if you do, I don't want you to do triamcinolone every day, but triamcinolone once a week and then the other days, doing one of your steroid sparing kind of gives you a little bit of the best of all worlds.
[17:52]
Dr. Sheila Fallon Friedlander
So when you look at the study published with reflumelast, you're looking at using the drug every day and then using it in twice a week. Didn't they? As I'm recalling. So they did a maintenance trial which showed that using it twice a week is enough to keep people good. That's not the exact answer to your question, but it's a similar idea. And the phone call that I got today was of a patient who was on desonide, who. It's a small kid and I don't want dasanide every day. So I was trying to get Zarev in there and so I started the Zarev and then I tried to taper the steroids and it failed. But that's an n of 1. So we do this frequently. And to be truthful, a kid with a very mild eczema comes in. I'm not going to start throwing all these drugs at that kid. I'm going to start out with, well, am I allowed to use brand names here? Derma Smooth oil. That should be in the water supply. I think it's very safe. And you get much more effect, much more bang for your back. So I'll start. And of course, everyone says the bottom of the pyramid, it's moisturizing, but when you say that to a family, their eyes start to glaze over. If you start out with, oh, you just have to moisturizers, you lose them. Yes. So the answer is yes. And the goal is. And I mean, with some kids, you know, you do the pulsing. If I could only get this kid on topical steroids twice a week, and let's say sorry for something else will hold them the rest of the time. I will do it. And we've been doing that with the topical calcineurin inhibitors and Amy Powell are published on that. So, I mean, I think we all know, even if the studies haven't been done, that if you get a kid in reasonable shape with whatever, then often you can do pulsing either every other day in the beginning or twice a week, and it will get them through.
[19:47]
Host/Interviewer
And farish. I'll say I do that for hand eczema with either nzupco or opzelura clobatazole once a day, on the weekends, and use the JAK inhibitor every day. All right, let's talk a little bit about Doopie, which has now been out for a while in the little tiny kids. I think my perception is that the big problem is, especially once they get to be like 2 to 6, where they don't really understand that it's making their eczema better, but they're able to fight back, the pain can be such a problem that almost there are some kids you cannot, like, they just won't take the shot. Am I right about that perception that that happens?
[20:33]
Dr. Sheila Fallon Friedlander
Well, I can tell your kid's old enough. And again, this is why peds is so interesting and complex. It's age dependent. And you're saying, oh, shell, I'm already gonna zoom in on that age group. But the older kids are often the worst in terms of their fear. So you have to break it down in terms of, is it fear or is it actual pain? And then you have to try to address both of those. Your single most important weapon in this battle against fear and pain and is a good nurse. And by nurse, they don't have to be an np. They don't have to. They can be a medical assistant, but it's someone who loves children, who understands, and who will sit down and talk with them. And for many kids, if they're old enough, one of my nurses will say, well, this is the angel's pinch. Now, not to bring religion or politics.
[21:25]
Host/Interviewer
Angels pinch, but just think about it. Trademark. Trademark Angel's pinch.
[21:30]
Dr. Sheila Fallon Friedlander
You know, here's the thing. Angel doesn't have necessarily a religious. You know, it's like, oh, you're such an angel. Yeah, yeah. So you try to tell them and, you know, slapping you, it's an angel's touch.
[21:46]
Guest/Colleague
You've been touched by an angel.
[21:47]
Host/Interviewer
Yes.
[21:48]
Dr. Sheila Fallon Friedlander
Punch. Punch. And, you know, you've heard this before, but you can. Do not lie that is, don't tell
[21:55]
Host/Interviewer
them it's not as.
[21:56]
Guest/Colleague
It doesn't hurt at all.
[21:57]
Dr. Sheila Fallon Friedlander
Yeah, it doesn't hurt. You will lose them forever. So you say, yeah, in the beginning, and then you talk with them. So I've started out in the easier. I'm saving your harder question for last. So you talk to them and you say, well, are you afraid? And then they tell you maybe they're afraid. And then you tell them about the Angel's pinch. And then you tell them about things that can be done. And one thing that's very helpful is the Buzzy. Do you guys know about the buzzy?
[22:23]
Host/Interviewer
Does that really work?
[22:24]
Dr. Sheila Fallon Friedlander
Oh, yeah.
[22:25]
Host/Interviewer
Well, do you start it proactively or do you. Because I feel like once they know it hurts a lot, the fear takes. So do you start the buzzy like on day one?
[22:35]
Dr. Sheila Fallon Friedlander
Well, depending on how crazy my clinic is and if I have my good nurses. I mean, I'm just honest with you. But the idea would be, well, there are certain things we can do. First of all, the idea would be you have a game in the room. You have a tablet, and you get them involved and distracted, and that is like a miracle, like lots of things, if you're doing even procedures. Kids are on their belly, but they're watching. It's so addictive, these tablets and these games. You have that for the kid. You also show them the buzzy. And they like the buzzy. It's great because you chill it. Do you all know how? And you can get it. You can order it online. And I'm trying to remember the name of the pain.com or something. I can look it up for you, but you can order it. And then it has a little ice chiller, you know, that you put in the freezer, and then you wrap it around it, and then you want to put it proximal to where you're going to be working. So, you know, theoretically, you're closer to the nerves. You're blocking. You're distracting the nerves from the pain below. And then you start it before you inject, and then you keep it going through the whole thing. I think it makes a major difference. Now, the other thing that some people will use is Elomax or topical Lidocaine. The thing about that is it takes 30 minutes, but I think there's probably a great placebo effect with that. And then again, we're into mysticism, magical numbing cream, so you can use it. So these are all the things that you can do.
[24:05]
Host/Interviewer
So let me ask you if I am out of my freaking mind for this.
[24:09]
Dr. Sheila Fallon Friedlander
So, what else is there?
[24:10]
Host/Interviewer
I would do the answer probably yes. If it's once a month, why not give them, like, a script for 2mg of Xanax and be like, okay, it's bedtime. It's time for your magic pill tonight. And then the kid is so out of it and they're not gonna remember it. And you just.
[24:28]
Dr. Sheila Fallon Friedlander
You're clearly not pediatrician. We don't roofie babies. You are clearly not a pediatrician. And you are clearly not the new generation of parents, nor a mother. Do you know the new generation of parents,
[24:42]
Host/Interviewer
once a month they'll be selling their buys. What about when I was a kid, my mom used to rub whiskey on my gums.
[24:52]
Dr. Sheila Fallon Friedlander
That explains. That explains a lot.
[24:55]
Host/Interviewer
We also don't just give him a shot.
[24:58]
Guest/Colleague
You don't give kids shots. Yeah, no liquor.
[25:02]
Host/Interviewer
It's a whole new thing. Hey, Joey, it's time for your shot. Okay, now it's time for your other shot.
[25:07]
Dr. Sheila Fallon Friedlander
We can say in this corner, we don't do those things. Maybe there are people who do them. Those are not recommended activities for once a month you can do. I mean. Yeah, I talked to a pediatrician who
[25:20]
Host/Interviewer
says he does never. He never uses the pen.
[25:22]
Dr. Sheila Fallon Friedlander
Always the syringe. Do you do that or the syringe? People like the idea of control. So I'm not on either or. Some patients have come back and requested one versus the other. Some people just like the idea it's in and it's over. But a lot of people like the idea. We're talking parents now. Of control. And the thing about the syringe is you can do a slow, steady injection. Oh, the other thing. Room temperature. When you're doing. You warm up. You warm up the product. You're warming the product, you're freezing the Buzzy. You're very busy. That's why you need a busy buzzy. Nurse.
[26:03]
Host/Interviewer
Magic Wizard Cream.
[26:07]
Guest/Colleague
Thank goodness it's only once a month.
[26:10]
Dr. Sheila Fallon Friedlander
Yeah, but I have to tell you the other thing. We wrestle kids down in peds for lots of things. And in that age where you're saying you cannot reason with them, these families, for the most part, have been suffering for a long time. So for the parents, they will deal with that shot and especially once they see improvement. And again, you know, in pediatrics, I'm going off on a sidebar. But what's made the big difference in pediatrics? Well, propranolol, which you mentioned. I was so happy you mentioned that the other day. And then Dupixent So for families and for docs, Dupixent has been amazing. And I know you're mentioning the newer drugs and certainly the first one that came out, you know, what about a tablet, JAK inhibitor? I find that the vast majority of my patients will do okay on Dupixent. And sometimes I need to add a little topical and as I mentioned, I'll do. It's probably off label. When I get sued for saying this, I will use some Opzelura. So it's fulfilled a lot of needs. Now it may be down at Radi they're using more. I don't think so. I think for the vast majority of people right now, they're sticking with Dupixent. And then the other thing is we now have the track record. So we have drugs. You were talking about no pain.
[27:32]
Host/Interviewer
Yeah. Nemluvio shots don't hurt. And that's gonna be. I could see that being a big deal in kids. But. But dupy we know now reduces your risk of asthma. It's food allergy. And Nimlovio is not going to have any of those benefits.
[27:45]
Dr. Sheila Fallon Friedlander
And eosinophilic esophagitis, they're using depiction. But I'm one slow to change because I trained in peds first. So I took on all of those. You know, let mistakes be made on the adults first and gain experience and before starting a new drug. Now, obviously, if we don't have anything for a disease, then I'm going to go with a new drug. But right now I do feel like Dupixent is fulfilling a lot of.
[28:14]
Guest/Colleague
Does the height story help? Yes.
[28:16]
Host/Interviewer
Let's talk.
[28:17]
Dr. Sheila Fallon Friedlander
Let's talk about that.
[28:18]
Guest/Colleague
So, you know, we know that kids who are put on Dupixent actually attain. They have a better growth curve. Absolutely. I think it seems like. And I don't see kids, but it seems like that would be something that would be helpful to parents. So sometimes I think saying like there's a danger to not treating.
[28:35]
Dr. Sheila Fallon Friedlander
Absolutely.
[28:36]
Guest/Colleague
Here's one of the dangers is like your kid may not attain their sort of your full height. And this is something. We actually have data that helps them to attain their full height. Does that help?
[28:48]
Dr. Sheila Fallon Friedlander
We. I actually talked about it at the lit review because there's now I think it was Jad where. And it's cute the terms were. They didn't say it accelerates growth, it mediates retardation of growth. But the whole point is that clearly. And you know, it's funny, Ilona Frieden, once she had a Terrible atopic derm patient and a very touchy feely family. And they were like, I don't want you to use anything that could do any harm. And I want all natural. And she said, and well, my kid won't be able to get into Harvard if, you know, and she said, well, your kid's not going to be able to go anywhere if you don't let him get some sleep. So that's the kind of thing like that fear. You are absolutely right. The fear of foreign agents entering my baby's body as opposed to he'll be able to grow and he'll be able to sleep. Absolutely.
[29:41]
Host/Interviewer
In theory, dupixent is natural. It comes from an organism. Right. Chinese hamster ovary cells taking it too far.
[29:50]
Dr. Sheila Fallon Friedlander
Well, you know, one day I wasn't feeling good. I was in clinic, I think I was passing a kidney stone, to tell you the truth. And this mother was going on and on and she said, you know, that she didn't want anything unnatural. And I evidently, my fellows tell me that I got up and said, death is natural. I walked down the room. You're not going to use that. But anyway, that's not a pearl.
[30:18]
Host/Interviewer
That's not a pearl.
[30:20]
Dr. Sheila Fallon Friedlander
But the point is that if you. The whole idea of natural, that's got
[30:27]
Guest/Colleague
to be so much worse in California than it is in Pittsburgh or North Carolina.
[30:31]
Host/Interviewer
It's a. Speaking of natural, one last topic I want to hit on.
[30:34]
Dr. Sheila Fallon Friedlander
You didn't do measles yet.
[30:36]
Host/Interviewer
Okay, we'll get to it. So one more thing. And then measles. Molluscum, are you a believer in. So I think wycanth is great. Do you use much wycanth or are you in the camp of like, that's just too expensive?
[30:51]
Dr. Sheila Fallon Friedlander
So did you hear the peds ID section I did today where I spent 15 minutes going over the literature recent about molluscum. And in the old days we didn't have anything good for molluscum. So the kids would come in and the pediatricians would say, oh, that's natural, don't worry about it, it's going to go away. And then we learned that for some people, molluscum hangs around for years, not months, and it spreads. And these kids are stigmatized. So now that we have, I think two good treatments. One, why can't treatment which I use all the time, I think it's very important to get the message out that molluscum isn't like a small plantar ward. It can be very debilitating. And one of the studies Showed? Well, several studies showed that when a kid comes in with molluscum, should you tell all of them, oh, you're going to be fine, go away? No, you actually should find out if that kid has a history of atopic dermatitis, because one of the studies showed that when you looked at all the patients, they looked at patients with atopic derm and molluscum. Atopic derma alone, Molluscum alone. And they found that the kids who had atopic derm and molluscum took much longer to respond to treatment.
[32:08]
Host/Interviewer
I did not know that.
[32:09]
Dr. Sheila Fallon Friedlander
Yeah, yeah, it's in the notes. So anyway, to me, that is very helpful. We've got these two drugs and then there were still people saying, oh, you don't really need it. And I'm like, no, you need to get a history from your family. And if in the first visit you find out, oh, this kid's had terrible atopic dermot, I think you should go with treatment because we know it's going to be prolonged. I mean, so number of treatments is a surrogate marker for duration of disease. So I feel now that we have in the literature support, we need to be more aggressive again. I love this. Put it in the water supply. I wanted to do that with Timolol and now I'm. A lot of things in the water.
[32:51]
Host/Interviewer
A lot of stuff in the water,
[32:52]
Dr. Sheila Fallon Friedlander
a lot of mechanics in there. The water is not natural anymore, but I feel like I use so much wine.
[33:00]
Host/Interviewer
I'm picturing Sheila in San Diego right now, like dumping bottles of propranolol in. Down the drain to get it in the water supply.
[33:09]
Dr. Sheila Fallon Friedlander
I didn't say propranolol, I said Timolol, which is. It's the topical form, but it's a ridiculous idea. But anyway, so back to molluscum. I use a lot of white. Can I. There are several reasons. I love it. And I am not a paid speaker for Veruca. You know, I'm not. My experience that I've had in the last couple of years, number one, they put a dye in it. Do you remember the old days when you would try to treat molluscum with kentaridin and you'd be putting it on. Well, you never bother, I guess.
[33:38]
Host/Interviewer
But no, as a resident, I remember kids going to the ER though, because you would.
[33:42]
Dr. Sheila Fallon Friedlander
The blisters, right?
[33:43]
Host/Interviewer
The blisters would be so bad.
[33:46]
Dr. Sheila Fallon Friedlander
One of the reasons the blisters were so bad is you would retreat places and you couldn't remember. I would be like, there are 20 spots. Did I do that? I don't know. Did I do it? Well, let's just double touch. So anyway, there's now a violet dye in this container. It's easy. It's one time. You use it, you throw it away, you crunch it. And I have had less reactions with ycant than I did with regular Kentin.
[34:13]
Host/Interviewer
The thing that they don't promote enough. The vehicle has this matrix in it so that once it old cantheridine. Even once it dried, if you then went like it would smear around the matrix they have. Once it dries, it can't spread around.
[34:30]
Dr. Sheila Fallon Friedlander
That's it, buddy. And supposedly it tastes terrible or not. I don't know.
[34:34]
Host/Interviewer
It has a bittering agent.
[34:35]
Dr. Sheila Fallon Friedlander
Yes. So I think there are several reasons why it's great. Now, I have to be honest. About a year ago I was using it and families were complaining. This costs a fortune. I'm getting these big bills. And so the company came out with a coupon program and we got scripts to buy into having the product there for me not having to order it every time you want it. So we use a tremendous amount of it. I think that it's a fantastic aid for most families. Now you could say I'm hearing good things. Maybe the people are having bad times mortality or to another doctor, I don't know. My sense is that most families are really pretty happy. We are not getting the er. Blisters as much.
[35:23]
Guest/Colleague
And it's natural. From a beetle.
[35:25]
Host/Interviewer
From a beetle. Do you know there are blister beetles in Pennsylvania and Ohio? Yeah. I had a patient come in one time who had like a line of blisters on their arm. And they were like. There were these weird bugs on my hostas and I was cleaning the hostas and I was like, sounds like a blister. So I thought they only lived in Africa, but they live in.
[35:44]
Dr. Sheila Fallon Friedlander
Yeah, better that than the spiders or snakes, Right?
[35:47]
Host/Interviewer
All right, so let's talk about measles.
[35:49]
Dr. Sheila Fallon Friedlander
Okay. But we have to say Berdasmir. I felt like we. There were a couple problems with Berdasmir. One that they got approved. But then there was some manufacturing glitch so we couldn't get it for the longest time. It is now available but. But this teaches you about marketing. I think we can't is in the niche. I know it works. And also for parents. I think if you could one and done with the berdasamere. They're gonna have to do it at home. They have to mix.
[36:19]
Host/Interviewer
They're gonna mix it up, keep it in the fridge twice A day.
[36:23]
Dr. Sheila Fallon Friedlander
I am not using Berdasmir at the moment, to be honest. Theoretically, I understand why it would make sense. And I'm so grateful that you wanna talk about measles for just one second, so.
[36:32]
Host/Interviewer
Cause I've never seen a case of measles. I don't know if I've ever seen a case of chickenpox since I had it. As. Like, how do you.
[36:40]
Dr. Sheila Fallon Friedlander
You had such an insulated upbringing and training. No, in fact, most people. I missed a case of measles at UCLA when I was in training. So, I mean, I guess I saw it, but I didn't. Anyway, so what's measles like?
[36:53]
Host/Interviewer
What's. What's the. Do they get sick first? Does it. Do they get a cough? Like, I have no idea.
[36:58]
Dr. Sheila Fallon Friedlander
Anything about measles. We did go through that today and there are. First of all, they get this morbiliform rash and, you know, as derms. We're not supposed to say morbilliform, Right?
[37:08]
Host/Interviewer
Is it morbilif? Literally mean measles like milliflore means. Is measles like.
[37:14]
Dr. Sheila Fallon Friedlander
Right. But what I show today is the first thing in the first few days of the illness, when they have the rash, it's more discreet and it's at the top of the body. And then it starts working its way down. And as it works its way down, the top parts become more confluent. They're not as discreet, whereas if you looked at the bottom on the legs, they're still discrete and they're not as dense. So that's one thing to help. What I wanted to do was have these people leave with a sense of, how can I distinguish this from another rash? So it's not from the belly out, it's more top and down. The other thing is, if you had the sense to look in the mouth in the first few days of the rash, you would find Koplik spots.
[37:57]
Host/Interviewer
What do complex spots look like?
[37:58]
Dr. Sheila Fallon Friedlander
They are. I have never seen them except in pictures. But I talked to Ted Rosen and he said my pictures are right on the mark. They're little white to bluish. Papules or papula. More papules that are on the buccal mucosa. But the problem is after the third day of rash, second or third day of rash, they're gone, baby. The public spots are very transient. So what are you left with? You're looking for a kid who has fever. Coryza. The nose is running the three Cs, conjunctivitis. Their eyes look terrible. And then I made Copic spot, a C. And it's not. It's a K. But now you could say genetically it works. So what's the difference between that and another viral. It's not all that specific initially, but if you have that combination of fever, terrible conjunctival injection, coryza, then you need to be thinking about this. And then the history of the rash, how it started from the top, it was a little more discreet, and then it made its way down. And then as made its way down, the top parts became more confluent, I think, and you have to have an index of suspicion. And then the other thing that helps now, which I mentioned, they are assessing the incidence of measles via wastewater surveillance. Have you heard about this?
[39:18]
Guest/Colleague
Yes, yes. See if it's detectable and at what sort of concentration or PCR cycle threshold to see how much is out there and then history.
[39:27]
Dr. Sheila Fallon Friedlander
But this is really important. So there was a recent New England journal article about colocalization of exposures and vaccination. So if, you know, in your town there's been measles, then obviously, you know, we all have to try to keep up to date with what's going on because it will come if our vaccination practices continue. I mean, people don't want to put their child at risk. There's so much negative. And that's why I focus on today, on sspe, because, oh, now you're in for big trouble. I'm gonna tell you in a minute. But the reason is you can talk to reasonable people and they'll say in the same way, we used to have chickenpox parties. Do you remember? So now people are like that about measles. Oh, you know, go. You know, the kids can get measles and they'll be fine. First of all, not everybody who gets measles is fine. People do get hospitalized. But the other problem is this thing called sspe. It's subacute sclerosing pan encephalitis. Now, when I was an ID fellow, they said, oh, it's one in a million. So I decided not to learn about it because there was too much to worry about. But now we've realized one in a million was when we didn't know how to identify it and when measles wasn't so common. So the first thing. So it's caused by the wild measles virus. The problem is it doesn't show up till 6 to 10 years after infection. What? Please read about this or go through at least my notes. 10 years later, no sometimes 25. No.
[41:01]
Host/Interviewer
So.
[41:01]
Dr. Sheila Fallon Friedlander
And in the old days, who cared because it's so rare? So there were a couple questions that had to be answered. One, could the measles vaccine cause sspe? And initially, when the vaccination came out, experts were worried about that. Then the publications showed, and the study showed no. In fact, as we're using more vaccines, there's less sspe. So it's very clear that this SSPE comes from wild measles virus. It doesn't come from the vaccine. Now, you may get a naysayer too, but there's no data for it. So then if it's only one in a million, why are we worried? Well, what we've discovered there was. There were several studies, one that came out of California. The public health department kept track of how much SSPE was around after an outbreak, and they found that it's not one in a million. It's very high if a child contracted measles in the first two years of life. So this is really important because a lot of people say, oh, if you're so worried about, she'll vaccinate yourself and vaccinate your kids. But in fact, we can't vaccinate. We usually don't vaccinate with measles for kids less than two because it doesn't work as well because trans placental antibodies from the mom, so the kid will get. They'll have some trans placental antibodies, so the vaccinations don't work so well. So that's why we don't give measles vaccine till 12 to 15 months of age. But what does that mean? That means all those babies are out
[42:32]
Guest/Colleague
there, only their mother in return.
[42:36]
Dr. Sheila Fallon Friedlander
And if the mother never got vaccinated, they're out there with nothing. So that could make a case if the incidence in moms is so low, maybe they'll start vaccinating but earlier in life. But so the people who are at highest risk are the ones who we can't vaccinate. And so the study came out of California where the incidence was really high in children less than two if they were. So then I'm reading and I'm looking. There's an article, outbreak of SSPE in Georgia. And I got, oh, so upset. And I called my aunt in Atlanta and I said, how are you doing? She said, what's wrong with you? There's no outbreaks of anything. It was Russian Georgia. Okay, but here's the deal. Does it matter whether it's Russian Georgia or Georgia Georgia? Here again, two outbreaks and they followed what happened six to 10 years after the outbreaks. SSPE goes up.
[43:33]
Host/Interviewer
All right, so Sheila, if you see a case of measles, measles, scream. Is there any treatment? And if you get that call, I think my kid's got measles. Are you like, don't bring them here.
[43:45]
Dr. Sheila Fallon Friedlander
That's straight to the er. Do you have them with the hazmat?
[43:49]
Host/Interviewer
And is there a confirmatory test?
[43:51]
Dr. Sheila Fallon Friedlander
Is there like a serology? What I think for the average Joe out there in general, I don't think derms should be dealing with this. I think right now, pediatricians and infectious disease people. So you make the call. You make the call to your county health department, your state health department, and you keep that kid. As you said. Do you really want that kid coming into your office? Probably not. I would keep them at home until you talk with the health department officials who are available. And this happened at Rady, I remember. And I had a couple of kids about. When was that. There was an outbreak in Disneyland. Was that. Do you remember that? Yeah, I do vaguely remember. Yeah. So then that was a big deal. And I had a couple cases where they recommend you keep the kids in isolation. It is incredibly infectious. And the problem is that they're infectious four days before the rash comes on to four days after. So what I would ask of our audience is if you think that's what you're dealing with, call the pediatrician, who would be appropriate. If you can't get the pediatrician, then call the state health department, because I think the pediatrician. Pediatricians are more used to dealing with this kind of thing. So I don't want you guys to all have the numbers listed where you have to call. I just want you to recognize it and make sure that case is isolated until the proper people can come in. And then they will test and they can confirm. Is it a blood test, A swab, like. I have no idea, to tell you the truth. I don't know which. They use PCR in general, and I'm not sure which ones they depend on more. But a lot of. A lot of PCR is now being done by nasopharyngeal for like mycoplasma and a lot of others. And, you know, it's a good question. I should go back and see what the most up to date thing is. But I didn't even worry about that because I wasn't the one doing it. My job was to get the questionable cancer.
[45:49]
Guest/Colleague
Different health systems are going to have different protocols on what to do. So it's almost like go ask. Call your health department, get your local program.
[45:57]
Dr. Sheila Fallon Friedlander
Yeah. And you can't calling the CDC isn't as helpful as you have to call your county and local health department.
[46:03]
Host/Interviewer
Okay. Well, Sheila, thank you for coming on this attendance.
[46:06]
Dr. Sheila Fallon Friedlander
Thanks for learning eloquent about me.
[46:08]
Host/Interviewer
Yeah, that was. I now am more educated about measles.
[46:12]
Dr. Sheila Fallon Friedlander
Please read about sspe because I think with any person they might say I don't care if my kid gets measles.
[46:19]
Host/Interviewer
But they don't want. It's so interesting as we're finding out more about. So I don't know if you guys knew this, but Ms. Everybody who gets Ms. Has had ebv. Like it is necessary. It's not sufficient, obviously, but it is necessary. It is a co founder. Literally Everybody who has Ms. Now 95% of the population has had EBV anyways. But if you've never had ebv, literally you cannot get Ms. And so there's EBV vaccine. They're working on it.
[46:50]
Dr. Sheila Fallon Friedlander
Yeah, that's being developed. The other thing that would be interesting is there are certain age when it's. It's better. So a lot of things I've read in the past are that EBV early in life is much safer than getting EBV later. But I don't so that send people
[47:04]
Host/Interviewer
to have kissing parties.
[47:06]
Dr. Sheila Fallon Friedlander
I mean like Xanax a little while they won't even need the Xanax.
[47:13]
Host/Interviewer
Again, Sheila, thank you for coming on this.
[47:15]
Dr. Sheila Fallon Friedlander
It was a pleasure.
[47:16]
Guest/Colleague
Thank you.
[47:17]
Dr. Sheila Fallon Friedlander
Thank you so much.

Summary7 min read

Podcast Summary: Derms on Drugs – "Creams, Screams, and Measles"

Date: August 7, 2026
Featuring: Dr. Sheila Fallon Friedlander with Hosts Dr. Matt Zirwas, Dr. Laura Ferris, and Dr. Tim Patton (Scholars in Medicine)

Episode Overview

In this engaging and fast-paced episode, the "Derms on Drugs" crew welcomes pediatric dermatologist Dr. Sheila Fallon Friedlander for a candid, in-depth discussion. Topics include the rapidly expanding landscape of topical treatments for pediatric atopic dermatitis, practical tips on managing dupilumab (Dupixent) injections in kids, and a vital review of molluscum therapy and measles recognition. The episode is packed with clinical pearls, practical advice for navigating parental fears and pharmacy nightmares, and memorable moments that blend clinical rigor with the show’s trademark wit.

Meet the Guest: Dr. Sheila Fallon Friedlander

Background: Emeritus at UC San Diego and on staff at Scripps (00:18)
Career Path: Pediatrician by training, did infectious disease, then dermatology at UCLA; worked with Dr. Larry Eichenfield at UCSD for ~30 years (00:36–01:54)
Philosophy: Advocates for practical, patient-first approaches in pediatric dermatology, loves infection and dermatology’s intellectual (and readable) side (01:36–01:54)

The New Era in Topical Pediatric Dermatitis: More Choices, More Nuance

Setting the Scene: Old vs. New Options

Past Options: Steroids (families fearful), tacrolimus/pimecrolimus (burning, not super effective), Eucrisa (burned, weak) (02:01–03:58)
Now: Three new "great drugs" (Opzelura, Zoriv, Vitama) with shifting safety, efficacy, and application profiles (02:49–04:00)

Quote:
"In most cases, [Eucrisa] wasn't all that strong. However, it's all I had, so I used a lot of it. And it's safe, which families loved… But all of a sudden we had Roflumilast, we had tipirinoff. I guess that Ruxolitinib has been out there… just in the last year or two that people really started… using in Pete's cases."
— Dr. Fallon Friedlander (04:25)

Key Drugs Discussed

1. Ruxolitinib (Opzelura®)

Strengths: Highly effective, “it really works” (06:25)
Concerns: Boxed warning & absorption risks (parent and primary peds fear), BID dosing less practical for families (06:00–07:12)
- “Talking to a parent about a boxed warning is not easy.” – Host (05:58)
- Pediatricians are “taught not to use anything new for at least five years. Let all the mistakes be made in the adults.” (06:00)
Absorption risk: Limit to <20% BSA and 1 tube/2 weeks; recent data show low systemic exposure but lingering concern (“below myelosuppressive dose”) (07:53–09:06)

2. Tapinarof (Vitama®)

Strengths: “Good drug, daily, impressive/happy results even in tough cases,” very well tolerated, QD dosing is a plus (10:32–11:36)
Drawbacks: Mechanism (AHR pathway) is hard to explain to patients/families; a bit of a black box for providers, too (10:00–10:32; 10:54)
Host notes surprisingly fast results compared to expectations:
“Shocking to me how fast it works.” (11:13)

3. Roflumilast (Zoriv®)

Strengths: Good for Seb Derm and atopic dermatitis; useful across various presentations; multiple concentrations and formulations (12:56–13:43)
Drawbacks: Multiple concentrations can confuse families; perceived as least potent among new topicals (12:56–13:56)
Class familiarity: Phosphodiesterase inhibitors have historical safety data (theophylline in asthma etc.) (13:46)

Comparative Summary:

"I think of Opzelura as the most effective but the most safety concerns. I think of Zoriv as the fewest safety concerns but the least effective and Vatama almost as the Goldilocks."
– Host (15:01)

Dr. Friedlander agrees:
"That's what I was trying to say." (15:30)

Practical Pearls: Drug Selection

Decision based on age, severity, prior experience, and what’s available/covered (15:49–16:40)
Combination approaches sometimes used, especially when insurance coverage limits access; sometimes combining mechanisms “works better.” (17:04–17:26)
Tight insurance constraints often dictate options available (16:24–16:40)

Combining Topicals with Steroids

Maintenance with topical PDE4s after initial steroid rescue is supported by data (“maintenance trial…using [Roflumilast] twice a week is enough to keep people good”) (17:52–18:52)
General principle: Mild cases = start low, moisturizers, escalate as needed; regular pulsing (intermittent steroids plus topicals) works for many (18:52–19:46)

Injections, Screams, and Dupilumab: Tackling the Kid Factor

The Dupilumab Challenge: Fear and Pain

Kids (especially 2–6 y.o.) can be “impossible” when it comes to injections—the emotional component can outweigh physical pain (19:46–20:32)
“Angel’s pinch” and other reframings/distraction tools are essential; never lie to kids (“You will lose them forever” if you say “doesn’t hurt at all”) (21:24–21:56)
Buzzy device: Highly recommended—cold packs and vibration to dull nerves, with pre-injection distraction methods (tablet/games) (22:23–24:04)
“Magical numbing cream” (Elomax/Lidocaine) is useful for placebo and some real effect, but takes time (22:24–24:04)

Quote:
"Your single most important weapon in this battle against fear and pain is a good nurse. Someone who loves children, who understands, who will sit down and talk with them."
— Dr. Fallon Friedlander (20:32)

Host’s Offbeat Suggestions—Rejected!

Suggestion of pre-shot Xanax or whiskey humorously rebuffed: “You are clearly not a pediatrician…We don’t roofie babies.” (24:27–24:41)
Multiple options for delivery: Pen vs. syringe, with some parents preferring sense of control, others wanting quick over (25:01–25:22)
Key: Warming product, chilling Buzzy, leveraging staff—“That’s why you need a busy buzzy nurse.” (26:03)

Why Families Persevere with Dupixent

Impact: Dramatic improvement, seen as a miracle by families after years of suffering (26:10–26:30)
Ongoing preference: Dupixent remains gold standard due to efficacy, long track record, and downstream benefits (asthma, food allergies, EoE) (27:31–27:44)

Growth Curve Data as a Parental Counseling Point

Dupixent seems to prevent the growth retardation that can happen with undertreated eczema—“They have a better growth curve. Absolutely.” (28:13–28:35)
“Sometimes I think saying like there's a danger to not treating…your kid may not attain their full height.” (28:34)

Counseling Against “All Natural” Bias

Families sometimes paralyzed by fear of “foreign” substances; Dr. Friedlander uses real-talk, evidence about quality of life and long-term outcomes to put things in perspective (29:49)
“Death is natural.” – memorable (and darkly comic) anecdote for difficult conversations (29:49)

Molluscum Contagiosum: New Treatments, New Practices

“Wycanth” (cantharidin formulation) praised as breakthrough—"I use all the time, I think it's very important" (30:51–32:07)
Key Point: Kids with atopic derm + molluscum have longer, tougher courses—should treat more aggressively; “number of treatments is a surrogate marker for duration of disease" (32:07)
New formulation with violet dye prevents over-treatment, less risk of blisters (33:00–34:13)
"One and done" concept with berdasmir is promising, but not yet widely used due to logistical/manufacturing barriers (35:49–36:22)
“Put it in the water supply!” motif is a running joke about wishful thinking for widespread, easy access (13:43; 32:50; 33:09)

Measles: Recognizing and Reacting to a “Resurging” Threat

Classic Measles Clinical Signs (36:31–39:18)

Rash starts at the top (“more discreet, at the top of the body, then works its way down”); upper areas become more confluent as it spreads
Koplik spots: White/blue papules on the buccal mucosa, fleeting—gone by day 2–3 of rash (37:56)
Three C’s: Coryza, Conjunctivitis, Cough; add “C” for Koplik spots
Importance of keeping up with local disease prevalence; wastewater surveillance and contact tracing are now public health tools (39:18)

SSPE: The Long-Term Danger (40:00–43:33)

Subacute Sclerosing Panencephalitis (SSPE) risk is higher than previously thought, especially if measles infection occurs <2 years of age
SSPE is delayed by years or decades (“doesn't show up till 6 to 10 years after infection. Sometimes 25.” – 41:00)
SSPE is not caused by vaccine-strain, only wild-type measles; “as we’re using more vaccines, there’s less SSPE” (41:01–41:52)
Unvaccinated infants <1 year are at risk (“the people…who we can't vaccinate”) (42:31)

Management in Suspected Measles

Don’t bring suspect cases to your office—call peds/ID and local health department immediately, keep potential case isolated (43:44–45:57)
Testing: PCR/serology, but protocols differ—public health manages (45:49–46:03)
If you recognize the rash, focus on exposure control and public health notification

Quote:
"If you think that's what you're dealing with, call the pediatrician...call your county health department, your state health department, and you keep that kid [isolated]…"
— Dr. Fallon Friedlander (43:50)

Notable Quotes & Memorable Moments

“You are clearly not the new generation of parents, nor a mother. Do you know the new generation of parents…” – Dr. Friedlander (24:27)
“Death is natural.” – Dr. Friedlander, referencing a frustrated clinic day with ‘natural only’ parents (29:49)
"Put it in the water supply!" – Dr. Friedlander’s running joke for favorite treatments (13:39, 32:50, 33:09)
"Angel's pinch" — a positive reframing for injections (21:24)

Key Takeaways & Clinical Pearls

Topical Advances: New non-steroidal topicals are expanding options but require nuanced, family-specific use—Vitama emerges as the “Goldilocks” choice.
Parental Counseling: Address real fears, leverage evidence about disease burden and long-term outcomes; never downplay pain or lie to kids.
Practical Tips: Distraction and Buzzy devices for shots, pulse therapy for steroid sparing, and mix-and-match topicals when insurance allows.
Measles Vigilance: Know (and suspect) the evolving presentation, use public health resources not just your own practice.
SSPE Awareness: Long-term complications are potent counseling points amid vaccine hesitancy.

Timestamps for Key Segments

Introductions and Sheila’s Story: 00:04–01:54
Modern Topical Options Debate: 02:01–15:32
Choosing/Combining Topicals: 15:32–17:46
Dupixent Injections: Fear, Pain, and Management: 19:46–26:10
Dupixent Impact—Growth, “Natural” Skepticism: 27:31–29:49
Molluscum Overview and Treatment Update: 30:34–36:31
Measles Clinical Pattern and Practice Response: 36:31–46:03
Closing Pearls and Anecdotes: 46:03–47:16

This episode is a must-listen for practical derm pearls, real-world stories, and a blend of infectious humor and poignant clinical experiences. Dr. Sheila Fallon Friedlander’s expertise shines as she cuts through the complexity to offer actionable advice, while the hosts provide just enough comic relief to make the learning stick.

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Transcript179 lines

[00:04]
Host/Interviewer
Thrilled to have Dr. Sheila Fallon Friedlander here with us. So for any of our listeners who don't know Dr. Fallon Friedlander, she is a pediatric dermatologist extraordinaire. You're at UC San Diego.
[00:19]
Dr. Sheila Fallon Friedlander
I'm emeritus at ucsd and I'm on staff at Scripps.
[00:23]
Host/Interviewer
Okay, so you have been peds derming for too long. When did you start? When did you.
[00:32]
Dr. Sheila Fallon Friedlander
Do you really want to know this?
[00:34]
Host/Interviewer
I want to know when did you start pedsderming?
[00:36]
Dr. Sheila Fallon Friedlander
No, I started out in pediatrics because I remember being in the emergency room where I trained and seeing what the PDR was like compared to the adult er. So you walk through the doors to the adult ER and the smell just overwhelms you. Of the diabetics and everybody, you know, you're on the wrong edge of the curve. You know, you're in the wrong spot. And I thought, well, in peds we could probably make things better. So I started out in peds and I loved it, but I was sort of OCD and I there night and day. And, you know, when I was a chief, I didn't come home. But I always realized, too, I loved infections. So I did two years of infectious diseases and that. And then while I was doing that, I realized, God, we're cross consulting and all the derm consults, only they get to read more. Idaho fellows are tortured. I'm just going to tell you right now, it's a wonderful field. But I realized if I did derm, I could read more. And I might occasionally see my husband. So that's my story. And then the last part of my training was in Durham at ucla. And then Larry Eichenfeld needs someone to help him at UCSD. And I was there for 30 some years. Okay, yeah, about that.
[01:54]
Host/Interviewer
30 some years.
[01:55]
Dr. Sheila Fallon Friedlander
No, I can't be that old. Maybe.
[01:57]
Guest/Colleague
Yeah, we started at 10.
[01:59]
Dr. Sheila Fallon Friedlander
Yes, yes, yes. I was precocious. I was precocious.
[02:02]
Host/Interviewer
So to me, the most exciting. And I'm a dermatitis person, obviously. So the most exciting thing has been that we now have these three. We had no good topical options for kids, right? We had topical steroids, which parents are all afraid of. We had TCIs, which, you know, tacrolimus burned in so many kids. Pomecrolimus just didn't work all that great. And now we've suddenly got. And then we got. We had Eucrisa, which burns. And then now we've got three great drugs that are very well tolerated, very effective, the whole thing. But I'm not Pedsderm. How do you pick? Like, so you're like, when do you use Opzelura? When do you use Zoriv? When do you use.
[02:48]
Dr. Sheila Fallon Friedlander
Yeah, okay.
[02:49]
Host/Interviewer
And we're allowed to use brand names.
[02:51]
Dr. Sheila Fallon Friedlander
You may want to cut this out later. But it's so funny when you do the lit. We do this every year together. These literate. And I was thinking this year, what's the most important thing for this audience to go home with? I must be getting old. And I'm, you know, anyway, so I'm thinking about this not what I will look good or smart. And. And I decided the drugs and the use of the drugs, the new drugs and the information we have about peds atopic derm. So I proceeded to talk about the three drugs during my lit review and I got a dressing down.
[03:27]
Host/Interviewer
You got in trouble from the two bosses.
[03:32]
Dr. Sheila Fallon Friedlander
I was supposed to be doing a lit review, not drugs. I said the drugs are in the lit review. But, you know, new drugs comes right out of new drugs. I'm so glad you've asked me to talk about this because it makes me feel better. I think it is the most. And I rarely talk just about drugs in the literature, but I thought this is such a move forward for our patients. Well, dupixent, of course.
[03:55]
Host/Interviewer
Yeah, we're talking about dupixent.
[03:57]
Dr. Sheila Fallon Friedlander
Major, major, major.
[03:58]
Host/Interviewer
Yes, we're gonna get to that.
[03:59]
Dr. Sheila Fallon Friedlander
But in the last year or two, we have so many choices. As you said, it used to be. Well, my husband would say, if it's wet, dry it. If it's dry, wet it. And if that doesn't work, throw an ointment on it. That's sort of eczema too. But anyway, so. So we used to have topical steroids. The calcineurin inhibitors were a big move forward, but there's so many problems. The black box scared everybody to death. And the stinging, the stinging went along with them. And they're not as strong as the topical steroids. Come on, let's face it. So then Chrisaboro came along and I was so excited, mostly because it's down to three months to have drug FDA approved. Of course, the insurance companies might not have happy, but I was very happy. I had something FDA approved and then I used it. And in some cases it is helpful, especially for the face, you know, when you. What are your options? Steroids or the calcineurin inhibitors. But in most cases, it wasn't all that strong. However, it's all I had, so I used a lot of it. And it's safe like the families loved. Oh, it's boron based. Oh, it's not the evil steroid. Yes. This is wonderful. Okay, so. So then all of a sudden we had Roflumilast, we had tipirinoff. I guess that Ruxolitinib has been out there sort of sitting around making sense. We should have used it. But it's just in the last year or two that people have really started in my world, using in Pete's cases. So where do we stand about which drugs are the best? Well, what do we want to talk about? Do we want to talk about fear? So, you know, human fear, practitioner fear. Ruxolitanum. People are still a little concerned. It's a JAK inhibitor. You very sophisticated people will tell me there's nothing to worry about with jaks. But the fact of the matter is,
[05:59]
Host/Interviewer
talking to a parent about a boxed warning is not easy.
[06:01]
Dr. Sheila Fallon Friedlander
Exactly. And the pediatricians, what you need to remember is your pediatric practitioners are taught not to use anything new for at least five years. Let all the mistakes be made in the adults. Okay, so. So it was something with a black box on it. And so Ruxlitinib, even, I think, and I'm just gonna say empirically, it is so great. Rex Litinib.
[06:25]
Host/Interviewer
Yeah, it works. Really, really works.
[06:28]
Dr. Sheila Fallon Friedlander
It really works. But there are a couple of things that work against us. One bid versus qd. I mean, I love the fact that the other two are QD approved daily rather than twice a day. It makes a difference in a two career family. Let's just say they're just hanging in there. They're trying their kids up in the morning, they're trying to get them out. If you only have to put something on once a day, you could sort of determine the moment you have. So the fact that ruxolitinib is twice a day. So twice the work, if you're going to follow the advice. But the major concern, and you could say it's all hypothetical, but I still think the major concern is the issue of absorption and what the absorption can do.
[07:12]
Host/Interviewer
Yeah. Because and for our listeners who didn't, maybe not everybody remembers this from residency kids. There's two things. There's the body to surface area to volume ratio. So they have relatively more body surface,
[07:28]
Dr. Sheila Fallon Friedlander
body surface area, body surface area volume. It's like we have all these crevices in the babies. It's a way of looking at it. So you can put a tremendous amount on for a very little baseline weight. Yes.
[07:42]
Host/Interviewer
And it's easy to cover with an adult, you can't treat 20% of their body with a cream. With a baby, it's not that hard to treat 100%. Just put it all over and it's a really important. You really then can get significant levels.
[07:54]
Dr. Sheila Fallon Friedlander
And that plays an important role because in approving this drug, they said body surface area ratio less than 20%. So they're out of the gate saying, don't put it on more than 20%. And then the other part they now have is or one 60 gram tube every two weeks, you're allowed to prescribe for the younger kids. So, okay, when you're busy trying to explain to a family, oh, this is perfectly safe, but don't you put more
[08:21]
Guest/Colleague
than a tube into.
[08:22]
Dr. Sheila Fallon Friedlander
Yeah, yeah. So if it says that, I think you have families concern. Having said that, I understand it's a theory. Oh, and then there was a recent publication where they looked at absorption in kids and it is absorbed. But in the publication, which is not getting much press, they made great effort to say, but it was absorbed below the myelosuppressive dose. Did you see that?
[08:48]
Guest/Colleague
I did.
[08:48]
Dr. Sheila Fallon Friedlander
And like nobody.
[08:49]
Guest/Colleague
It was the JAD paper. Was that the one in jad?
[08:51]
Dr. Sheila Fallon Friedlander
I'm pretty sure it was jad, but nobody's talking about it, which, I mean, it's so what I'm saying.
[08:56]
Host/Interviewer
And the point is the myelosuppression level is lower than. Is much higher than the immunosuppression level. Right. You can get immunosuppression without having myelosuppression.
[09:06]
Dr. Sheila Fallon Friedlander
Having said all of that, we will probably find out that it's totally safe, that it's totally safe. But when you're dealing with pediatric patients, pediatric doctors and pediatricians, they're going to have some concern and I think they're going to want to give it a little more time unless there's nothing else out there. So now to me, Opzolar works great. I love it. In the older kids, where I'm not using it in a lot of areas, I think it's a wonderful drug. In the younger kids, there are a lot of other issues. So would I use it? Yes, but not first line. So now we have two others. And to pin her off, Vitama. Initially I was like, I don't understand how it works. So maybe I'm not going to, you know, the aryl hydrocarbon receptor. There's no way I could talk about this as a meeting. I'm sure it's clear for some, but not for me.
[10:01]
Host/Interviewer
No, we don't Really, I mean, we know some of the stuff it does, but we don't really. That is a really complicated pathway. Like, there are so many different things. So it is a ligand. Its activities are ligand dependent. So depending what binds to AHR and activates it, it does different things. Right. In different states. So it's. It. While I feel like, oh, I understand. Like, it's just not a well understood pathway in general, it seems to work
[10:27]
Guest/Colleague
in multiple different, like cell types and disease states. And so. Yeah.
[10:32]
Dr. Sheila Fallon Friedlander
Which then can sort of throw you off because we want things to be as specific as they can be. But anyway, you're making me feel better having explained that. It's hard to explain. So initially I. Well, I don't understand how it works. But then I decided, hey, I'm going to try it. Look, it's approved all the way down. I've had great results.
[10:55]
Host/Interviewer
So I did the trials for both psoriasis and ad and when we started to do the AD trial, I was like, oh, man, this is good. Because I was expecting to be kind of slow. It's a good psoriasis drug. It is a really good atopic derm drug. It is shocking to me how fast it works.
[11:14]
Dr. Sheila Fallon Friedlander
Agreed.
[11:14]
Host/Interviewer
It's crazy.
[11:15]
Dr. Sheila Fallon Friedlander
Kids who were having trouble with just about everything and I'm like, just hold because I had some samples in the office or whatever. It's really a good drug and it's daily now. What problems? I've had some folliculitis with it. I've had some people complain, but it's very exciting to me how well it works.
[11:34]
Host/Interviewer
And it's got the perfect. Put it on once a day, anywhere
[11:36]
Dr. Sheila Fallon Friedlander
you got eczema every day. Qd. Qd. When you hear that re, eczema goes
[11:40]
Host/Interviewer
away, stop putting it on, comes back, start putting it on again.
[11:43]
Guest/Colleague
So how do you think it compares to Zerve then?
[11:46]
Dr. Sheila Fallon Friedlander
We're getting to Zariv. It's next on our list. Zarive. Sometimes I've had some patients who loved it. I just got a call today from a mother who said, oh, you made me taper into. From my steroids into Zarev. And it's doing nothing. So, you know, it's only an n of 1. I've had other patients who seem to really like it. But the confusing part of Zariv initially was the three concentrations, which. And so if you're trying to talk to people about it, well, why are you giving me this one versus that? And again, back to Matt's point. It's all about Very sophisticated, intelligent people designing their trials and realizing that absorption could be an issue. Where do we want these 80 drugs to be used? Well, most AD people are little kids. You know, the incidence is much higher in young kids. So I think the company looked at it and said, we're going to make a concentration that's low. Well, first they showed, to my understanding, that it worked at various.
[12:51]
Host/Interviewer
And the three concentrate, there's.05, 0.15 and 0.3.
[12:56]
Dr. Sheila Fallon Friedlander
Yeah.
[12:57]
Host/Interviewer
Is that right?
[12:57]
Dr. Sheila Fallon Friedlander
And the ones. The foam too?
[12:59]
Host/Interviewer
Yeah, yeah. Then there's the foam and there's 0.3 foam and a 0.3 cream. And then I think a 0.15 cream. And a 0.05 cream.
[13:06]
Dr. Sheila Fallon Friedlander
Yeah. So the point to them, I think, was let's go with the lowest concentration. That will work. And guess what? The lowest concentration does work. So in explaining that to families, and again, you could say, what's my big hold up? You need to be able to explain things in a way that will make sense. So now that I've realized, number one, I think Zuri works well. I also love it for Septerma. I can sort of throw it on anything. I was thinking about maybe the water supply. Do you think we could throw it in? But I think that it works for a lot of us.
[13:39]
Host/Interviewer
They should come up with a powder you put in the bath, right? That's a very good idea.
[13:44]
Dr. Sheila Fallon Friedlander
That's right.
[13:45]
Host/Interviewer
A powder you put in the bath.
[13:47]
Dr. Sheila Fallon Friedlander
Yeah. So first of all, families have to understand because then when you say it's a lower concentration. Oh, is it dangerous then? And you know what I tell families, as a pediatrician, I was working with PD4 inhibitors 30 years ago because all the asthma meds. Theophylline. Yeah. So I was using theophylline all the time. So I understood phosphodiesterase inhibitors. And we had so much experience with it that I realized systemically, even, of course, there's side effects. But a lot of experience with that class so that I find reassuring. And sometimes if I'm really crazy, I'll try to explain how it works. And we want more cyclic amp around, but most days I have too much sense to do that. So I think that both of those drugs, all three of them, have a role in my hands. Very conservative. I don't know how well you know me, but I'm pretty conservative. You know, I'm not going to take a risk. Dermatologist, you guys are all, save the baby. So, anyway, in my experience, initially I was going to go Roflumulast oreve I'm going to use that and I do like it. But I have been so impressed with my results with vitamin and I didn't know whether it's just me, but you're
[15:02]
Host/Interviewer
telling you did the trials and it's, you know, the way that I think about it. And so because in adults, the way I think about it. So it sounds like the same thing goes in kids, but it's even more important in kids. I think of Opzelura as the most effective but the most safety concerns. I think of Zoriv as the fewest safety concerns but the least effective and Vatama almost as the Goldilocks. And do you.
[15:27]
Dr. Sheila Fallon Friedlander
You're pretty good at summarizing things, by the way.
[15:30]
Host/Interviewer
Thank you.
[15:30]
Dr. Sheila Fallon Friedlander
That's what I was trying to say.
[15:32]
Host/Interviewer
Do you recommend one to families or do you give them like, okay, here are these three creams we could pick from. This one works the best, but it's got some safety concerns. This one's the safest, but it doesn't work as well. Or do you tell people this is the one that I would use if it was my kid.
[15:50]
Dr. Sheila Fallon Friedlander
First of all, it depends on how old the kid is and what the experience is. So if I have had a kid with bad atopic dermatitis, a pre adolescent little bit older and maybe he needs a little boost or a kid on dupy and I want a little. And so maybe this is again the rules, but I will use Apsalura on a kid who's doing really pretty well on Doopie. But at week three he seems to start to run into trouble. So that's my audience for Opsolura out of the gate.
[16:19]
Host/Interviewer
By the way, I was confused for a moment there because I was like doopies every two weeks, but then in kids and some of the kids it's every four.
[16:25]
Dr. Sheila Fallon Friedlander
Okay, okay, sorry about that. So it depends. So for that group I use a lot of Apsalur. Do you want to know the real truth? What's around, what samples I have and what can I get through insurance?
[16:40]
Guest/Colleague
Insurance drugs.
[16:41]
Dr. Sheila Fallon Friedlander
Can you prescribe like two of those for the same people or is that like insurance?
[16:49]
Host/Interviewer
I have been able to do it if I prescribe for one for Seb Derm and one for ad or if I do one for psoriasis and one for AD sometimes I've been able to get that.
[17:02]
Dr. Sheila Fallon Friedlander
But do you have them use it on similar body surfaces or not?
[17:05]
Host/Interviewer
Yes. And so I'll do. Right. I'll do, you know, Vitamma once a day and it's for somebody who's not doing well and I still want to stay topical, we'll do Vitama once a day and Zoriv once a day or, you know, something like that.
[17:17]
Dr. Sheila Fallon Friedlander
So what's your experience doing this clinical trial sorts?
[17:21]
Host/Interviewer
I think it works better. I think doing that. I think the different mechanisms of action to Panera.
[17:26]
Dr. Sheila Fallon Friedlander
I think we know opzelure is the best. We are. I mean, we're in agreement. I think that's.
[17:32]
Host/Interviewer
I think it's the most effective.
[17:33]
Dr. Sheila Fallon Friedlander
Yeah.
[17:33]
Host/Interviewer
And it's the fastest. All right, let's change gears though. So.
[17:36]
Guest/Colleague
But I want to ask one last question. Do you guys ever combine these with topical steroids? Like if you said, you know, look, if you do, I don't want you to do triamcinolone every day, but triamcinolone once a week and then the other days, doing one of your steroid sparing kind of gives you a little bit of the best of all worlds.
[17:52]
Dr. Sheila Fallon Friedlander
So when you look at the study published with reflumelast, you're looking at using the drug every day and then using it in twice a week. Didn't they? As I'm recalling. So they did a maintenance trial which showed that using it twice a week is enough to keep people good. That's not the exact answer to your question, but it's a similar idea. And the phone call that I got today was of a patient who was on desonide, who. It's a small kid and I don't want dasanide every day. So I was trying to get Zarev in there and so I started the Zarev and then I tried to taper the steroids and it failed. But that's an n of 1. So we do this frequently. And to be truthful, a kid with a very mild eczema comes in. I'm not going to start throwing all these drugs at that kid. I'm going to start out with, well, am I allowed to use brand names here? Derma Smooth oil. That should be in the water supply. I think it's very safe. And you get much more effect, much more bang for your back. So I'll start. And of course, everyone says the bottom of the pyramid, it's moisturizing, but when you say that to a family, their eyes start to glaze over. If you start out with, oh, you just have to moisturizers, you lose them. Yes. So the answer is yes. And the goal is. And I mean, with some kids, you know, you do the pulsing. If I could only get this kid on topical steroids twice a week, and let's say sorry for something else will hold them the rest of the time. I will do it. And we've been doing that with the topical calcineurin inhibitors and Amy Powell are published on that. So, I mean, I think we all know, even if the studies haven't been done, that if you get a kid in reasonable shape with whatever, then often you can do pulsing either every other day in the beginning or twice a week, and it will get them through.
[19:47]
Host/Interviewer
And farish. I'll say I do that for hand eczema with either nzupco or opzelura clobatazole once a day, on the weekends, and use the JAK inhibitor every day. All right, let's talk a little bit about Doopie, which has now been out for a while in the little tiny kids. I think my perception is that the big problem is, especially once they get to be like 2 to 6, where they don't really understand that it's making their eczema better, but they're able to fight back, the pain can be such a problem that almost there are some kids you cannot, like, they just won't take the shot. Am I right about that perception that that happens?
[20:33]
Dr. Sheila Fallon Friedlander
Well, I can tell your kid's old enough. And again, this is why peds is so interesting and complex. It's age dependent. And you're saying, oh, shell, I'm already gonna zoom in on that age group. But the older kids are often the worst in terms of their fear. So you have to break it down in terms of, is it fear or is it actual pain? And then you have to try to address both of those. Your single most important weapon in this battle against fear and pain and is a good nurse. And by nurse, they don't have to be an np. They don't have to. They can be a medical assistant, but it's someone who loves children, who understands, and who will sit down and talk with them. And for many kids, if they're old enough, one of my nurses will say, well, this is the angel's pinch. Now, not to bring religion or politics.
[21:25]
Host/Interviewer
Angels pinch, but just think about it. Trademark. Trademark Angel's pinch.
[21:30]
Dr. Sheila Fallon Friedlander
You know, here's the thing. Angel doesn't have necessarily a religious. You know, it's like, oh, you're such an angel. Yeah, yeah. So you try to tell them and, you know, slapping you, it's an angel's touch.
[21:46]
Guest/Colleague
You've been touched by an angel.
[21:47]
Host/Interviewer
Yes.
[21:48]
Dr. Sheila Fallon Friedlander
Punch. Punch. And, you know, you've heard this before, but you can. Do not lie that is, don't tell
[21:55]
Host/Interviewer
them it's not as.
[21:56]
Guest/Colleague
It doesn't hurt at all.
[21:57]
Dr. Sheila Fallon Friedlander
Yeah, it doesn't hurt. You will lose them forever. So you say, yeah, in the beginning, and then you talk with them. So I've started out in the easier. I'm saving your harder question for last. So you talk to them and you say, well, are you afraid? And then they tell you maybe they're afraid. And then you tell them about the Angel's pinch. And then you tell them about things that can be done. And one thing that's very helpful is the Buzzy. Do you guys know about the buzzy?
[22:23]
Host/Interviewer
Does that really work?
[22:24]
Dr. Sheila Fallon Friedlander
Oh, yeah.
[22:25]
Host/Interviewer
Well, do you start it proactively or do you. Because I feel like once they know it hurts a lot, the fear takes. So do you start the buzzy like on day one?
[22:35]
Dr. Sheila Fallon Friedlander
Well, depending on how crazy my clinic is and if I have my good nurses. I mean, I'm just honest with you. But the idea would be, well, there are certain things we can do. First of all, the idea would be you have a game in the room. You have a tablet, and you get them involved and distracted, and that is like a miracle, like lots of things, if you're doing even procedures. Kids are on their belly, but they're watching. It's so addictive, these tablets and these games. You have that for the kid. You also show them the buzzy. And they like the buzzy. It's great because you chill it. Do you all know how? And you can get it. You can order it online. And I'm trying to remember the name of the pain.com or something. I can look it up for you, but you can order it. And then it has a little ice chiller, you know, that you put in the freezer, and then you wrap it around it, and then you want to put it proximal to where you're going to be working. So, you know, theoretically, you're closer to the nerves. You're blocking. You're distracting the nerves from the pain below. And then you start it before you inject, and then you keep it going through the whole thing. I think it makes a major difference. Now, the other thing that some people will use is Elomax or topical Lidocaine. The thing about that is it takes 30 minutes, but I think there's probably a great placebo effect with that. And then again, we're into mysticism, magical numbing cream, so you can use it. So these are all the things that you can do.
[24:05]
Host/Interviewer
So let me ask you if I am out of my freaking mind for this.
[24:09]
Dr. Sheila Fallon Friedlander
So, what else is there?
[24:10]
Host/Interviewer
I would do the answer probably yes. If it's once a month, why not give them, like, a script for 2mg of Xanax and be like, okay, it's bedtime. It's time for your magic pill tonight. And then the kid is so out of it and they're not gonna remember it. And you just.
[24:28]
Dr. Sheila Fallon Friedlander
You're clearly not pediatrician. We don't roofie babies. You are clearly not a pediatrician. And you are clearly not the new generation of parents, nor a mother. Do you know the new generation of parents,
[24:42]
Host/Interviewer
once a month they'll be selling their buys. What about when I was a kid, my mom used to rub whiskey on my gums.
[24:52]
Dr. Sheila Fallon Friedlander
That explains. That explains a lot.
[24:55]
Host/Interviewer
We also don't just give him a shot.
[24:58]
Guest/Colleague
You don't give kids shots. Yeah, no liquor.
[25:02]
Host/Interviewer
It's a whole new thing. Hey, Joey, it's time for your shot. Okay, now it's time for your other shot.
[25:07]
Dr. Sheila Fallon Friedlander
We can say in this corner, we don't do those things. Maybe there are people who do them. Those are not recommended activities for once a month you can do. I mean. Yeah, I talked to a pediatrician who
[25:20]
Host/Interviewer
says he does never. He never uses the pen.
[25:22]
Dr. Sheila Fallon Friedlander
Always the syringe. Do you do that or the syringe? People like the idea of control. So I'm not on either or. Some patients have come back and requested one versus the other. Some people just like the idea it's in and it's over. But a lot of people like the idea. We're talking parents now. Of control. And the thing about the syringe is you can do a slow, steady injection. Oh, the other thing. Room temperature. When you're doing. You warm up. You warm up the product. You're warming the product, you're freezing the Buzzy. You're very busy. That's why you need a busy buzzy. Nurse.
[26:03]
Host/Interviewer
Magic Wizard Cream.
[26:07]
Guest/Colleague
Thank goodness it's only once a month.
[26:10]
Dr. Sheila Fallon Friedlander
Yeah, but I have to tell you the other thing. We wrestle kids down in peds for lots of things. And in that age where you're saying you cannot reason with them, these families, for the most part, have been suffering for a long time. So for the parents, they will deal with that shot and especially once they see improvement. And again, you know, in pediatrics, I'm going off on a sidebar. But what's made the big difference in pediatrics? Well, propranolol, which you mentioned. I was so happy you mentioned that the other day. And then Dupixent So for families and for docs, Dupixent has been amazing. And I know you're mentioning the newer drugs and certainly the first one that came out, you know, what about a tablet, JAK inhibitor? I find that the vast majority of my patients will do okay on Dupixent. And sometimes I need to add a little topical and as I mentioned, I'll do. It's probably off label. When I get sued for saying this, I will use some Opzelura. So it's fulfilled a lot of needs. Now it may be down at Radi they're using more. I don't think so. I think for the vast majority of people right now, they're sticking with Dupixent. And then the other thing is we now have the track record. So we have drugs. You were talking about no pain.
[27:32]
Host/Interviewer
Yeah. Nemluvio shots don't hurt. And that's gonna be. I could see that being a big deal in kids. But. But dupy we know now reduces your risk of asthma. It's food allergy. And Nimlovio is not going to have any of those benefits.
[27:45]
Dr. Sheila Fallon Friedlander
And eosinophilic esophagitis, they're using depiction. But I'm one slow to change because I trained in peds first. So I took on all of those. You know, let mistakes be made on the adults first and gain experience and before starting a new drug. Now, obviously, if we don't have anything for a disease, then I'm going to go with a new drug. But right now I do feel like Dupixent is fulfilling a lot of.
[28:14]
Guest/Colleague
Does the height story help? Yes.
[28:16]
Host/Interviewer
Let's talk.
[28:17]
Dr. Sheila Fallon Friedlander
Let's talk about that.
[28:18]
Guest/Colleague
So, you know, we know that kids who are put on Dupixent actually attain. They have a better growth curve. Absolutely. I think it seems like. And I don't see kids, but it seems like that would be something that would be helpful to parents. So sometimes I think saying like there's a danger to not treating.
[28:35]
Dr. Sheila Fallon Friedlander
Absolutely.
[28:36]
Guest/Colleague
Here's one of the dangers is like your kid may not attain their sort of your full height. And this is something. We actually have data that helps them to attain their full height. Does that help?
[28:48]
Dr. Sheila Fallon Friedlander
We. I actually talked about it at the lit review because there's now I think it was Jad where. And it's cute the terms were. They didn't say it accelerates growth, it mediates retardation of growth. But the whole point is that clearly. And you know, it's funny, Ilona Frieden, once she had a Terrible atopic derm patient and a very touchy feely family. And they were like, I don't want you to use anything that could do any harm. And I want all natural. And she said, and well, my kid won't be able to get into Harvard if, you know, and she said, well, your kid's not going to be able to go anywhere if you don't let him get some sleep. So that's the kind of thing like that fear. You are absolutely right. The fear of foreign agents entering my baby's body as opposed to he'll be able to grow and he'll be able to sleep. Absolutely.
[29:41]
Host/Interviewer
In theory, dupixent is natural. It comes from an organism. Right. Chinese hamster ovary cells taking it too far.
[29:50]
Dr. Sheila Fallon Friedlander
Well, you know, one day I wasn't feeling good. I was in clinic, I think I was passing a kidney stone, to tell you the truth. And this mother was going on and on and she said, you know, that she didn't want anything unnatural. And I evidently, my fellows tell me that I got up and said, death is natural. I walked down the room. You're not going to use that. But anyway, that's not a pearl.
[30:18]
Host/Interviewer
That's not a pearl.
[30:20]
Dr. Sheila Fallon Friedlander
But the point is that if you. The whole idea of natural, that's got
[30:27]
Guest/Colleague
to be so much worse in California than it is in Pittsburgh or North Carolina.
[30:31]
Host/Interviewer
It's a. Speaking of natural, one last topic I want to hit on.
[30:34]
Dr. Sheila Fallon Friedlander
You didn't do measles yet.
[30:36]
Host/Interviewer
Okay, we'll get to it. So one more thing. And then measles. Molluscum, are you a believer in. So I think wycanth is great. Do you use much wycanth or are you in the camp of like, that's just too expensive?
[30:51]
Dr. Sheila Fallon Friedlander
So did you hear the peds ID section I did today where I spent 15 minutes going over the literature recent about molluscum. And in the old days we didn't have anything good for molluscum. So the kids would come in and the pediatricians would say, oh, that's natural, don't worry about it, it's going to go away. And then we learned that for some people, molluscum hangs around for years, not months, and it spreads. And these kids are stigmatized. So now that we have, I think two good treatments. One, why can't treatment which I use all the time, I think it's very important to get the message out that molluscum isn't like a small plantar ward. It can be very debilitating. And one of the studies Showed? Well, several studies showed that when a kid comes in with molluscum, should you tell all of them, oh, you're going to be fine, go away? No, you actually should find out if that kid has a history of atopic dermatitis, because one of the studies showed that when you looked at all the patients, they looked at patients with atopic derm and molluscum. Atopic derma alone, Molluscum alone. And they found that the kids who had atopic derm and molluscum took much longer to respond to treatment.
[32:08]
Host/Interviewer
I did not know that.
[32:09]
Dr. Sheila Fallon Friedlander
Yeah, yeah, it's in the notes. So anyway, to me, that is very helpful. We've got these two drugs and then there were still people saying, oh, you don't really need it. And I'm like, no, you need to get a history from your family. And if in the first visit you find out, oh, this kid's had terrible atopic dermot, I think you should go with treatment because we know it's going to be prolonged. I mean, so number of treatments is a surrogate marker for duration of disease. So I feel now that we have in the literature support, we need to be more aggressive again. I love this. Put it in the water supply. I wanted to do that with Timolol and now I'm. A lot of things in the water.
[32:51]
Host/Interviewer
A lot of stuff in the water,
[32:52]
Dr. Sheila Fallon Friedlander
a lot of mechanics in there. The water is not natural anymore, but I feel like I use so much wine.
[33:00]
Host/Interviewer
I'm picturing Sheila in San Diego right now, like dumping bottles of propranolol in. Down the drain to get it in the water supply.
[33:09]
Dr. Sheila Fallon Friedlander
I didn't say propranolol, I said Timolol, which is. It's the topical form, but it's a ridiculous idea. But anyway, so back to molluscum. I use a lot of white. Can I. There are several reasons. I love it. And I am not a paid speaker for Veruca. You know, I'm not. My experience that I've had in the last couple of years, number one, they put a dye in it. Do you remember the old days when you would try to treat molluscum with kentaridin and you'd be putting it on. Well, you never bother, I guess.
[33:38]
Host/Interviewer
But no, as a resident, I remember kids going to the ER though, because you would.
[33:42]
Dr. Sheila Fallon Friedlander
The blisters, right?
[33:43]
Host/Interviewer
The blisters would be so bad.
[33:46]
Dr. Sheila Fallon Friedlander
One of the reasons the blisters were so bad is you would retreat places and you couldn't remember. I would be like, there are 20 spots. Did I do that? I don't know. Did I do it? Well, let's just double touch. So anyway, there's now a violet dye in this container. It's easy. It's one time. You use it, you throw it away, you crunch it. And I have had less reactions with ycant than I did with regular Kentin.
[34:13]
Host/Interviewer
The thing that they don't promote enough. The vehicle has this matrix in it so that once it old cantheridine. Even once it dried, if you then went like it would smear around the matrix they have. Once it dries, it can't spread around.
[34:30]
Dr. Sheila Fallon Friedlander
That's it, buddy. And supposedly it tastes terrible or not. I don't know.
[34:34]
Host/Interviewer
It has a bittering agent.
[34:35]
Dr. Sheila Fallon Friedlander
Yes. So I think there are several reasons why it's great. Now, I have to be honest. About a year ago I was using it and families were complaining. This costs a fortune. I'm getting these big bills. And so the company came out with a coupon program and we got scripts to buy into having the product there for me not having to order it every time you want it. So we use a tremendous amount of it. I think that it's a fantastic aid for most families. Now you could say I'm hearing good things. Maybe the people are having bad times mortality or to another doctor, I don't know. My sense is that most families are really pretty happy. We are not getting the er. Blisters as much.
[35:23]
Guest/Colleague
And it's natural. From a beetle.
[35:25]
Host/Interviewer
From a beetle. Do you know there are blister beetles in Pennsylvania and Ohio? Yeah. I had a patient come in one time who had like a line of blisters on their arm. And they were like. There were these weird bugs on my hostas and I was cleaning the hostas and I was like, sounds like a blister. So I thought they only lived in Africa, but they live in.
[35:44]
Dr. Sheila Fallon Friedlander
Yeah, better that than the spiders or snakes, Right?
[35:47]
Host/Interviewer
All right, so let's talk about measles.
[35:49]
Dr. Sheila Fallon Friedlander
Okay. But we have to say Berdasmir. I felt like we. There were a couple problems with Berdasmir. One that they got approved. But then there was some manufacturing glitch so we couldn't get it for the longest time. It is now available but. But this teaches you about marketing. I think we can't is in the niche. I know it works. And also for parents. I think if you could one and done with the berdasamere. They're gonna have to do it at home. They have to mix.
[36:19]
Host/Interviewer
They're gonna mix it up, keep it in the fridge twice A day.
[36:23]
Dr. Sheila Fallon Friedlander
I am not using Berdasmir at the moment, to be honest. Theoretically, I understand why it would make sense. And I'm so grateful that you wanna talk about measles for just one second, so.
[36:32]
Host/Interviewer
Cause I've never seen a case of measles. I don't know if I've ever seen a case of chickenpox since I had it. As. Like, how do you.
[36:40]
Dr. Sheila Fallon Friedlander
You had such an insulated upbringing and training. No, in fact, most people. I missed a case of measles at UCLA when I was in training. So, I mean, I guess I saw it, but I didn't. Anyway, so what's measles like?
[36:53]
Host/Interviewer
What's. What's the. Do they get sick first? Does it. Do they get a cough? Like, I have no idea.
[36:58]
Dr. Sheila Fallon Friedlander
Anything about measles. We did go through that today and there are. First of all, they get this morbiliform rash and, you know, as derms. We're not supposed to say morbilliform, Right?
[37:08]
Host/Interviewer
Is it morbilif? Literally mean measles like milliflore means. Is measles like.
[37:14]
Dr. Sheila Fallon Friedlander
Right. But what I show today is the first thing in the first few days of the illness, when they have the rash, it's more discreet and it's at the top of the body. And then it starts working its way down. And as it works its way down, the top parts become more confluent. They're not as discreet, whereas if you looked at the bottom on the legs, they're still discrete and they're not as dense. So that's one thing to help. What I wanted to do was have these people leave with a sense of, how can I distinguish this from another rash? So it's not from the belly out, it's more top and down. The other thing is, if you had the sense to look in the mouth in the first few days of the rash, you would find Koplik spots.
[37:57]
Host/Interviewer
What do complex spots look like?
[37:58]
Dr. Sheila Fallon Friedlander
They are. I have never seen them except in pictures. But I talked to Ted Rosen and he said my pictures are right on the mark. They're little white to bluish. Papules or papula. More papules that are on the buccal mucosa. But the problem is after the third day of rash, second or third day of rash, they're gone, baby. The public spots are very transient. So what are you left with? You're looking for a kid who has fever. Coryza. The nose is running the three Cs, conjunctivitis. Their eyes look terrible. And then I made Copic spot, a C. And it's not. It's a K. But now you could say genetically it works. So what's the difference between that and another viral. It's not all that specific initially, but if you have that combination of fever, terrible conjunctival injection, coryza, then you need to be thinking about this. And then the history of the rash, how it started from the top, it was a little more discreet, and then it made its way down. And then as made its way down, the top parts became more confluent, I think, and you have to have an index of suspicion. And then the other thing that helps now, which I mentioned, they are assessing the incidence of measles via wastewater surveillance. Have you heard about this?
[39:18]
Guest/Colleague
Yes, yes. See if it's detectable and at what sort of concentration or PCR cycle threshold to see how much is out there and then history.
[39:27]
Dr. Sheila Fallon Friedlander
But this is really important. So there was a recent New England journal article about colocalization of exposures and vaccination. So if, you know, in your town there's been measles, then obviously, you know, we all have to try to keep up to date with what's going on because it will come if our vaccination practices continue. I mean, people don't want to put their child at risk. There's so much negative. And that's why I focus on today, on sspe, because, oh, now you're in for big trouble. I'm gonna tell you in a minute. But the reason is you can talk to reasonable people and they'll say in the same way, we used to have chickenpox parties. Do you remember? So now people are like that about measles. Oh, you know, go. You know, the kids can get measles and they'll be fine. First of all, not everybody who gets measles is fine. People do get hospitalized. But the other problem is this thing called sspe. It's subacute sclerosing pan encephalitis. Now, when I was an ID fellow, they said, oh, it's one in a million. So I decided not to learn about it because there was too much to worry about. But now we've realized one in a million was when we didn't know how to identify it and when measles wasn't so common. So the first thing. So it's caused by the wild measles virus. The problem is it doesn't show up till 6 to 10 years after infection. What? Please read about this or go through at least my notes. 10 years later, no sometimes 25. No.
[41:01]
Host/Interviewer
So.
[41:01]
Dr. Sheila Fallon Friedlander
And in the old days, who cared because it's so rare? So there were a couple questions that had to be answered. One, could the measles vaccine cause sspe? And initially, when the vaccination came out, experts were worried about that. Then the publications showed, and the study showed no. In fact, as we're using more vaccines, there's less sspe. So it's very clear that this SSPE comes from wild measles virus. It doesn't come from the vaccine. Now, you may get a naysayer too, but there's no data for it. So then if it's only one in a million, why are we worried? Well, what we've discovered there was. There were several studies, one that came out of California. The public health department kept track of how much SSPE was around after an outbreak, and they found that it's not one in a million. It's very high if a child contracted measles in the first two years of life. So this is really important because a lot of people say, oh, if you're so worried about, she'll vaccinate yourself and vaccinate your kids. But in fact, we can't vaccinate. We usually don't vaccinate with measles for kids less than two because it doesn't work as well because trans placental antibodies from the mom, so the kid will get. They'll have some trans placental antibodies, so the vaccinations don't work so well. So that's why we don't give measles vaccine till 12 to 15 months of age. But what does that mean? That means all those babies are out
[42:32]
Guest/Colleague
there, only their mother in return.
[42:36]
Dr. Sheila Fallon Friedlander
And if the mother never got vaccinated, they're out there with nothing. So that could make a case if the incidence in moms is so low, maybe they'll start vaccinating but earlier in life. But so the people who are at highest risk are the ones who we can't vaccinate. And so the study came out of California where the incidence was really high in children less than two if they were. So then I'm reading and I'm looking. There's an article, outbreak of SSPE in Georgia. And I got, oh, so upset. And I called my aunt in Atlanta and I said, how are you doing? She said, what's wrong with you? There's no outbreaks of anything. It was Russian Georgia. Okay, but here's the deal. Does it matter whether it's Russian Georgia or Georgia Georgia? Here again, two outbreaks and they followed what happened six to 10 years after the outbreaks. SSPE goes up.
[43:33]
Host/Interviewer
All right, so Sheila, if you see a case of measles, measles, scream. Is there any treatment? And if you get that call, I think my kid's got measles. Are you like, don't bring them here.
[43:45]
Dr. Sheila Fallon Friedlander
That's straight to the er. Do you have them with the hazmat?
[43:49]
Host/Interviewer
And is there a confirmatory test?
[43:51]
Dr. Sheila Fallon Friedlander
Is there like a serology? What I think for the average Joe out there in general, I don't think derms should be dealing with this. I think right now, pediatricians and infectious disease people. So you make the call. You make the call to your county health department, your state health department, and you keep that kid. As you said. Do you really want that kid coming into your office? Probably not. I would keep them at home until you talk with the health department officials who are available. And this happened at Rady, I remember. And I had a couple of kids about. When was that. There was an outbreak in Disneyland. Was that. Do you remember that? Yeah, I do vaguely remember. Yeah. So then that was a big deal. And I had a couple cases where they recommend you keep the kids in isolation. It is incredibly infectious. And the problem is that they're infectious four days before the rash comes on to four days after. So what I would ask of our audience is if you think that's what you're dealing with, call the pediatrician, who would be appropriate. If you can't get the pediatrician, then call the state health department, because I think the pediatrician. Pediatricians are more used to dealing with this kind of thing. So I don't want you guys to all have the numbers listed where you have to call. I just want you to recognize it and make sure that case is isolated until the proper people can come in. And then they will test and they can confirm. Is it a blood test, A swab, like. I have no idea, to tell you the truth. I don't know which. They use PCR in general, and I'm not sure which ones they depend on more. But a lot of. A lot of PCR is now being done by nasopharyngeal for like mycoplasma and a lot of others. And, you know, it's a good question. I should go back and see what the most up to date thing is. But I didn't even worry about that because I wasn't the one doing it. My job was to get the questionable cancer.
[45:49]
Guest/Colleague
Different health systems are going to have different protocols on what to do. So it's almost like go ask. Call your health department, get your local program.
[45:57]
Dr. Sheila Fallon Friedlander
Yeah. And you can't calling the CDC isn't as helpful as you have to call your county and local health department.
[46:03]
Host/Interviewer
Okay. Well, Sheila, thank you for coming on this attendance.
[46:06]
Dr. Sheila Fallon Friedlander
Thanks for learning eloquent about me.
[46:08]
Host/Interviewer
Yeah, that was. I now am more educated about measles.
[46:12]
Dr. Sheila Fallon Friedlander
Please read about sspe because I think with any person they might say I don't care if my kid gets measles.
[46:19]
Host/Interviewer
But they don't want. It's so interesting as we're finding out more about. So I don't know if you guys knew this, but Ms. Everybody who gets Ms. Has had ebv. Like it is necessary. It's not sufficient, obviously, but it is necessary. It is a co founder. Literally Everybody who has Ms. Now 95% of the population has had EBV anyways. But if you've never had ebv, literally you cannot get Ms. And so there's EBV vaccine. They're working on it.
[46:50]
Dr. Sheila Fallon Friedlander
Yeah, that's being developed. The other thing that would be interesting is there are certain age when it's. It's better. So a lot of things I've read in the past are that EBV early in life is much safer than getting EBV later. But I don't so that send people
[47:04]
Host/Interviewer
to have kissing parties.
[47:06]
Dr. Sheila Fallon Friedlander
I mean like Xanax a little while they won't even need the Xanax.
[47:13]
Host/Interviewer
Again, Sheila, thank you for coming on this.
[47:15]
Dr. Sheila Fallon Friedlander
It was a pleasure.
[47:16]
Guest/Colleague
Thank you.
[47:17]
Dr. Sheila Fallon Friedlander
Thank you so much.