What are the treatment options for atopic dermatitis (eczema) in the pediatric population?

From the Guidelines

The treatment for eczema in the pediatric population should focus on a stepwise approach, starting with daily moisturizing and topical corticosteroids for mild to moderate cases, and progressing to stronger prescription steroids, non-steroidal alternatives, and systemic treatments for more severe cases, as outlined in the Taiwan guidelines for the diagnosis and management of pediatric atopic dermatitis 1. The first-line treatment includes daily moisturizing with fragrance-free emollients like petroleum jelly, CeraVe, or Eucerin, applied immediately after bathing to lock in moisture.

• For mild to moderate eczema, topical corticosteroids such as hydrocortisone 1% for the face and intertriginous areas or triamcinolone 0.1% for the body are effective, applied thinly twice daily for 7-14 days during flares.
• For moderate to severe cases, stronger prescription steroids may be needed, but should be used cautiously to avoid skin thinning.
• Non-steroidal alternatives include topical calcineurin inhibitors (tacrolimus 0.03% or pimecrolimus 1%) for sensitive areas. Some key considerations in the management of pediatric atopic dermatitis include:
• Bathing should be limited to 5-10 minutes in lukewarm water with gentle, fragrance-free cleansers.
• Wet wrap therapy can help severe flares by applying medication, moisturizer, then damp bandages covered by dry ones for 2-6 hours.
• Trigger avoidance is crucial—common triggers include harsh soaps, fragrances, certain fabrics (wool, polyester), dust mites, pet dander, and food allergens.
• For severe, uncontrolled eczema, systemic treatments like oral antihistamines (cetirizine, diphenhydramine) for itching or referral to a dermatologist for consideration of dupilumab (for children ≥6 years) may be necessary, as recommended in the Taiwan guidelines 1. It is essential to address the underlying skin barrier dysfunction and immune dysregulation through consistent skincare, and to consider the age of the patient, the site to be treated, and the extent of the disease when prescribing topical corticosteroids 1.

From the FDA Drug Label

CLINICAL STUDIES Three randomized, double-blind, vehicle-controlled, multi-center, Phase 3 studies were conducted in 589 pediatric patients ages 3 months-17 years old to evaluate ELIDEL ® (pimecrolimus) Cream 1% for the treatment of mild to moderate atopic dermatitis Two of the three trials support the use of ELIDEL Cream in patients 2 years and older with mild to moderate atopic dermatitis In these studies, patients applied either ELIDEL Cream or vehicle cream twice daily to 5% to 96% of their BSA for up to 6 weeks At endpoint, based on the physician’s global evaluation of clinical response, 35% of patients treated with ELIDEL Cream were clear or almost clear of signs of atopic dermatitis compared to only 18% of vehicle-treated patients.

The treatment for eczema in the pediatric population is pimecrolimus (ELIDEL) Cream 1%, which can be applied twice daily to affected areas for up to 6 weeks, and is supported for use in patients 2 years and older with mild to moderate atopic dermatitis 2.

• Key benefits of this treatment include:
  • Improvement in physician’s global evaluation of clinical response
  • Reduction in erythema and infiltration/papulation
  • Decrease in pruritus
• Age range: 2-17 years old
• Application: twice daily to 5% to 96% of body surface area (BSA) for up to 6 weeks.

From the Research

Treatment Options for Eczema in the Pediatric Population

• The treatment for eczema in the pediatric population typically involves a combination of pharmacologic and non-pharmacologic approaches 3.
• Irritant avoidance and liberal emollient usage are recommended as the cornerstone of treatment in all age groups 3.
• Topical corticosteroids are considered first-line medication-based therapy for infants under 2 years, with pimecrolimus, a topical calcineurin inhibitor, also being an option for infants as young as 3 months 3.

Topical Corticosteroids

• Topical corticosteroids are a mainstay of treatment for atopic dermatitis (AD) in children, with stronger-potency corticosteroids being more effective than weaker-potency ones 4.
• Moderate-potency topical corticosteroids probably result in more participants achieving treatment success compared to mild-potency corticosteroids 4.
• Potent topical corticosteroids probably result in a large increase in the number of participants achieving treatment success compared to mild-potency corticosteroids 4.

Comparison of Topical Treatments

• Tacrolimus, a topical calcineurin inhibitor, has been shown to have statistically significant improvement in disease severity compared to weak topical corticosteroids 5.
• Janus kinase inhibitors, such as ruxolitinib, have been ranked among the most effective topical anti-inflammatory treatments for eczema, along with potent and very potent topical steroids and tacrolimus 0.1% 6.

Safety and Adverse Effects

• Local adverse events, such as abnormal skin thinning, are more common with higher-potency topical corticosteroids 4.
• The use of topical calcineurin inhibitors, such as tacrolimus, may help overcome adherence issues due to patient bias against topical corticosteroids 5.
• Skin thinning was not increased with short-term use of any topical steroid potency, but was reported in 0.3% of participants treated with longer-term topical steroids 6.