What are the treatment options for atopic dermatitis (atopic dermatitis) in a pediatric patient (child)?

From the Guidelines

Treatment for atopic dermatitis in children should prioritize a stepwise approach, starting with daily moisturizing, topical corticosteroids, and topical calcineurin inhibitors, as recommended by the Taiwan guidelines for the diagnosis and management of pediatric atopic dermatitis 1. The cornerstone of treatment is daily moisturizing with fragrance-free emollients like petroleum jelly, Eucerin, or CeraVe, applied immediately after bathing to lock in moisture. Some key points to consider in the treatment of atopic dermatitis in children include:

• For mild flares, low-potency topical corticosteroids such as hydrocortisone 1% cream can be applied twice daily for 7-14 days.
• For moderate to severe cases, medium-potency steroids like triamcinolone 0.1% may be needed, but should be used cautiously and for limited periods to avoid skin thinning.
• Topical calcineurin inhibitors (tacrolimus ointment or pimecrolimus cream) are non-steroidal alternatives particularly useful for sensitive areas like the face.
• Children should take short, lukewarm baths (5-10 minutes) using mild, fragrance-free soap, and wear soft cotton clothing while avoiding wool and synthetic fabrics.
• Identifying and avoiding triggers such as certain foods, dust mites, pet dander, and harsh soaps is essential.
• Antihistamines like cetirizine or diphenhydramine can help manage itching, especially at night.
• For severe cases unresponsive to these treatments, a dermatologist may prescribe systemic medications or phototherapy, as recommended by the international eczema council 1. It's worth noting that the decision to initiate systemic therapy should be made on a case-by-case basis, taking into account the severity of the disease, the patient's response to topical therapy, and the potential risks and benefits of systemic treatment 1.

From the FDA Drug Label

ELIDEL ® (pimecrolimus) Cream 1% is indicated as second-line therapy for the short-term and non-continuous chronic treatment of mild to moderate atopic dermatitis in non-immunocompromised adults and children 2 years of age and older, who have failed to respond adequately to other topical prescription treatments, or when those treatments are not advisable. Two of the three trials support the use of ELIDEL Cream in patients 2 years and older with mild to moderate atopic dermatitis

The treatment for atopic dermatitis in children is pimecrolimus (TOP) Cream 1%, specifically for those 2 years of age and older.

• Indications: Mild to moderate atopic dermatitis
• Patient age: 2 years and older
• Usage: Second-line therapy for short-term and non-continuous chronic treatment 2
• Key points:
  • Not indicated for use in children less than 2 years of age
  • Failed to respond adequately to other topical prescription treatments, or when those treatments are not advisable 2 2

From the Research

Treatment Options for Atopic Dermatitis in Children

• Topical corticosteroids are recommended as first-line medication-based therapy for infants <2 years 3
• Pimecrolimus, a topical calcineurin inhibitor, may also be used in infants as young as 3 months 3
• In children and adolescents >2 years, topical corticosteroids are still considered first-line therapies, but topical calcineurin inhibitors and topical PDE4 inhibitors can also be used 3
• Oral systemic immunosuppressants can be used in children ages 2-12 years whose atopic dermatitis fails to respond to prior treatments 3
• The biologic, dupilumab, is an additional therapeutic option for adolescents >12 years 3, 4

Emerging Therapies for Atopic Dermatitis

• Monoclonal antibodies against immunoglobulin E (IgE), interleukin (IL)-4 receptor subunit α, IL-5, IL-13, IL-31 receptor subunit α, IL-33, and thymic stromal lymphopoietin (TSLP) have been evaluated clinically for AD 4
• Small molecules such as baricitinib, abrocitinib, upadacitinib, and tradipitant are being investigated as emerging systemic therapies 4
• Novel topical agents, including topical phosphodiesterase 4 (PDE4) inhibitors, Janus kinase (JAK) inhibitors, aryl hydrocarbon receptor (AhR) modulating agents, and transient receptor potential vanilloid subfamily member 1 (TRPV1) antagonists, are under clinical investigation 4

Considerations for Treatment

• The selection of appropriate vehicle and potency of topical corticosteroids, as well as frequency of application, is crucial for effective treatment 5
• Patient preferences and duration of treatment should also be taken into account when selecting a treatment approach 5
• Non-steroidal ant-inflammatory agents, such as topical calcineurin inhibitors, can be a viable alternative to topical corticosteroids in certain cases 6, 7
• Medical device emollients can provide anti-oxidant, anti-protease, and anti-inflammatory activity, and aid in restoring the natural balance of lipids 7