Advances in Pediatric Dermatology Spotlight Diagnostic Precision and New Systemics

Pediatric dermatology is rapidly evolving, driven by sharper diagnostic frameworks and increasingly precise immunotherapies.¹ The Maui Derm Hawaii 2026 meeting has focused on the expansion of targeted therapies for inflammatory skin disease,² but a panel of experts took the stage to examine how this evolution impacts pediatric patients.¹ They highlighted how common diseases can masquerade as something else in children, how to recognize life-threatening reactions early, and how emerging systemic therapies are reshaping care for severe inflammatory and autoimmune skin disease.

When Common Conditions Aren’t What They Seem

Sheila Fallon Friedlander, MD, professor of clinical pediatrics and medicine (dermatology) at the University of California, San Diego School of Medicine and director of the Dermatology Fellowship Training Program at Rady Children’s Hospital, emphasized that pediatric skin disease often defies adult patterns. 

“I want to tell you about disguises…” she said. “There are things you see every day, all day, and they're really important to recognize. But then there are sometimes things that are hidden beneath the surface, and it's important at some point for us to be able to recognize those kids and give them the right therapy.”

Infantile eczema, for example, may actually represent psoriasis. Key clues include a strong family history, sharply demarcated erythema in the diaper area, thinner plaques, and poor response to low-potency topical steroids. Because biopsies can appear spongiotic, she stressed the importance of clinical judgment and revisiting the diagnosis when treatment fails.

She also discussed diffuse alopecia areata, which can mimic telogen effluvium. Dermoscopy, specifically the presence of exclamation point hairs and yellow dots, is critical for diagnosis. Friedlander recommends screening for autoimmune comorbidities and initiating treatment with topical or oral minoxidil (Rogaine; Pfizer), with escalation to Janus kinase inhibitors such as ritlecitinib (Litfulo; Pfizer) in extensive disease. Importantly, she noted that meaningful regrowth may not occur until 24 weeks or later.

Finally, she cautioned that pediatric melanoma is often amelanotic, nodular, and long-standing, particularly in pre-adolescents, and may be mistaken for benign lesions such as angiomas. Because adult ABCDE criteria—Asymmetrical, Border, Color, Diameter, Evolving³—fail in children, she urged a low threshold for biopsy of persistent or evolving lesions.

Distinguishing High-Risk Mucocutaneous Reactions

Vikash Oza, MD, associate professor in dermatology and pediatrics at the NYU Grossman School of Medicine, focused on 3 potentially fatal pediatric conditions: reactive infectious mucocutaneous eruption (RIME), Stevens–Johnson syndrome/toxic epidermal necrolysis (SJS/TEN), and drug reaction with eosinophilia and systemic symptoms (DRESS). He framed these as T-cell–mediated reactions driven by interactions between antigens, human leukocyte antigen (HLA) genotype, and the T-cell receptor repertoire.

A key clinical pitfall is “protopathic bias,” or incorrectly blaming a drug started shortly before rash onset, despite immunologically implausible timing. “We always have this protopathic bias in almost everything we do…” Oza explained. “A drug is started within 1 to 2 days of a prodrome, which is too short of a window to probably activate a T‑cell response, but always makes things kind of confusing.” He emphasized that a limited group of high-risk medications, particularly antiepileptics and certain antibiotics, warrants the most scrutiny.

Oza also outlined evolving criteria to distinguish infection-driven RIME from SJS/TEN, noting that classic SJS/TEN features often take time to fully declare and may require biopsy to exclude mimics. In DRESS, eosinophilia and atypical lymphocytosis may appear late; early clues such as facial or ear swelling are diagnostically valuable.

Therapeutically, Oza highlighted increasing use of targeted immunomodulation, including TNF-α inhibitors for SJS/TEN and RIME, and cyclosporine or JAK inhibitors for DRESS and TEN-like eruptions. Emerging molecular data implicating IFN-γ/STAT1 signaling support JAK inhibition, with early reports showing rapid improvement even in high-risk patients. Long-term dermatology follow-up is essential given recurrence, psychological sequelae, and later autoimmune disease.

Seeing the Unfamiliar Clearly

Ilona Frieden, MD, professor of pediatrics and dermatology at UC San Francisco, addressed why clinicians continue to encounter pediatric findings that seem entirely new. She advocated a systematic approach: using descriptive language in Google Scholar to identify patterns, then refining searches in PubMed once a likely diagnosis emerges.

She highlighted several benign but underrecognized pediatric entities, including transient abdominal telangiectasia of infancy, midline anterior neck infundibular cysts, feeding-associated forehead flushing, the transverse nasal root vein, sock- or mitten-line hyperpigmentation, and transient smooth muscle contraction of the skin. Her core message was that many “new” diagnoses reflect improved recognition rather than new disease.

“What strikes me is that I still see things that I quote, ‘never seen before,’ which just seems almost statistically improbable, but it continues to happen,” Frieden explained.

Optimizing Systemic Therapy

James “Jim” Treat, MD, professor of clinical pediatrics and dermatology at the Perelman School of Medicine at the University of Pennsylvania, reviewed the expanding systemic armamentarium for pediatric atopic dermatitis and psoriasis. Although targeted biologics and JAK inhibitors have transformed care, he noted that some children remain inadequately controlled. In such cases, broader agents such as methotrexate or cyclosporine remain valuable, particularly when multiple pathways or comorbidities are involved. He also previewed future bi- and tri-specific antibodies designed to block multiple cytokines simultaneously.

Dawn Eichenfield, MD, PhD, dermatologist at Rady Children’s Hospital, San Diego, and assistant professor of dermatology at UC San Diego School of Medicine, focused on dupilumab (Dupixent; Sanofi, Regeneron Pharmaceuticals), emphasizing mechanism-based prescribing across interleukin-4/-13–driven diseases. She discussed off-label pediatric uses, practical strategies to improve injection tolerance, safe dose spacing after sustained control, and management of dupilumab-associated ocular and facial dermatitis. She underscored the systemic burden of atopic dermatitis and the importance of proactive, long-term management.

Together, these talks reinforced that pediatric dermatology requires pediatric-specific diagnostic insight and thoughtful deployment of powerful new therapies. The risks of undertreating severe disease now rival the risks of treatment itself—and recognizing that balance is central to modern pediatric care.

References

1. Fallon Friedlander S, Oza V, Frieden I, Treat J, Eichenfield D. Pediatric dermatology 2026. Presented at: Maui Derm 2026; January 25-29, 2026; Maui, HI.
2. Grossi G. Clinical trial data signal a new era for atopic dermatitis, melanoma, and psoriasis. AJMC^®. January 26, 2026. Accessed January 28, 2026. https://www.ajmc.com/view/clinical-trial-data-signal-a-new-era-for-atopic-dermatitis-melanoma-and-psoriasis
3. Pietrangelo A. What Is the ABCDE Rule for detecting skin cancer? Healthline. February 10, 2022. Accessed January 28, 2026. https://www.healthline.com/health/skin-cancer/abcd-rule-for-skin-cancer