From the Guidelines
Severe atopic dermatitis in pediatric patients requires a stepwise treatment approach, starting with topical corticosteroids and moisturizers, and progressing to systemic treatments like dupilumab or immunomodulators for severe cases that do not respond to conventional therapy, as recommended by the Taiwan guidelines for the diagnosis and management of pediatric atopic dermatitis 1.
Treatment Options
The treatment of severe atopic dermatitis in pediatric patients involves a combination of topical and systemic therapies.
- Topical corticosteroids are the mainstay of treatment for inflammation control, with moderate potency (triamcinolone 0.1%) for the body and lower potency (hydrocortisone 1-2.5%) for the face and skin folds, applied twice daily for 7-14 days during flares.
- Topical calcineurin inhibitors like tacrolimus (0.03% for children) or pimecrolimus can be used for maintenance therapy, as they do not cause skin thinning.
- Systemic treatments, such as dupilumab injections for children 6+ years, or other immunosuppressants like cyclosporin, azathioprine, and methotrexate, may be necessary for severe cases that do not respond to topical therapy, as stated in the consensus statements for systemic treatments of AD 1.
Adjunct Therapies
Adjunct therapies, such as oral antihistamines, can be considered for reducing pruritus in AD, as recommended by the Taiwan guidelines 1.
- Wet wrap therapy can help during severe flares by applying medication, moisturizer, and then covering with damp gauze and dry clothing for 2-8 hours.
- Identifying and avoiding triggers like harsh soaps, fragrances, certain fabrics, and allergens is also crucial in managing atopic dermatitis.
Important Considerations
Long-term use of oral corticosteroids is not recommended due to an unfavorable risk-benefit profile, as stated in the consensus statements for systemic treatments of AD 1.
- Phototherapy is not recommended for children younger than 12 years due to unclear long-term safety profiles, as mentioned in the Taiwan guidelines 1.
- The combination of immunomodulators and phototherapy is also not recommended, as stated in the consensus statements for systemic treatments of AD 1.
From the FDA Drug Label
INDICATIONS AND USAGE Prednisolone sodium phosphate oral solution is indicated in the following conditions: Allergic States: Control of severe or incapacitating allergic conditions intractable to adequate trials of conventional treatment in adult and pediatric populations with: ... atopic dermatitis;
The treatment options for severe atopic dermatitis (eczema) in pediatric patients include oral prednisolone 2.
- Key points:
- Pediatric use: Prednisolone sodium phosphate oral solution is indicated for use in pediatric populations.
- Atopic dermatitis: It is specifically indicated for the control of severe or incapacitating allergic conditions, including atopic dermatitis. Note that clobetasol propionate topical solution is not recommended for use in pediatric patients under 12 years of age 3.
From the Research
Treatment Options for Severe Atopic Dermatitis in Pediatric Patients
- Topical corticosteroids are a crucial part of the treatment regimen for children with atopic eczema, as stated in the study 4.
- The 'wet wrap technique' has been found to be effective in treating children with acute erythrodermic eczema in an inpatient setting, according to the study 4.
- Oral and topical antibiotics may not be necessary for children with mild clinically infected eczema, as the study 5 found no significant difference in treatment outcomes with the addition of antibiotics.
- Fluticasone propionate cream 0.05% has been shown to be safe for the treatment of severe eczema in children as young as 3 months, as reported in the study 6.
- Management of severe atopic dermatitis in children may involve long-term maintenance therapy with topical treatments, as well as adjunctive treatments and second-line therapies such as narrowband ultraviolet light therapy and systemic immunosuppressants, according to the study 7.
- The order of application of emollient and topical corticosteroids does not appear to make a significant difference in the severity of atopic eczema in children, as found in the study 8.
Topical Corticosteroids and Emollients
- Topical corticosteroids should be used with caution in children, as they are at risk of developing side effects, as noted in the study 4.
- Emollients and topical corticosteroids are commonly prescribed for the treatment of atopic eczema in children, and their application can be in either order, according to the study 8.
Second-Line Therapies
- Narrowband ultraviolet light therapy and systemic immunosuppressants such as cyclosporine, azathioprine, mycophenolate mofetil, and methotrexate have been shown to be safe and effective in children with severe atopic dermatitis, as reported in the study 7.
- Biologic therapy has not been uniformly effective in childhood atopic dermatitis, according to the study 7.