What is the first line of treatment for atopic dermatitis in infants?

First-Line Treatment for Atopic Dermatitis in Infants

The first-line treatment for atopic dermatitis in infants consists of moisturizers (emollients) to restore skin barrier function, followed by low-potency topical corticosteroids for inflammation when necessary. 1

Basic Treatment Approach

Moisturizers/Emollients

• Apply fragrance-free emollients immediately after a 10-15 minute lukewarm bath or shower 1
• Use multiple times daily, especially during acute phases 2
• Continue regular application even when skin appears normal to prevent relapse 2
• Moisturizers provide both short-term and long-term steroid-sparing effects in mild to moderate atopic dermatitis 1

Bathing Practices

• Short lukewarm baths (10-15 minutes) followed by immediate moisturizer application 1, 2
• Avoid hot water, harsh soaps, and irritating cleansers
• Consider gentle preservative-free formulations for cleansing 2

Treatment Algorithm for Atopic Dermatitis in Infants

For Mild AD:

1. Basic therapy: Emollients, trigger avoidance, education 1
2. Reactive therapy: Low-potency topical corticosteroids (TCS) when flares occur 1
3. Alternative options: Topical calcineurin inhibitors (pimecrolimus) or topical PDE-4 inhibitors (crisaborole) 1

For Moderate AD:

1. Basic therapy: Continue emollients and trigger avoidance 1
2. Preferred treatment: Proactive and reactive therapy with low to medium potency TCS 1
3. Other options: Topical calcineurin inhibitors (pimecrolimus, tacrolimus) or topical PDE-4 inhibitor (crisaborole) 1

For Severe AD:

1. Basic therapy: Continue emollients and trigger avoidance 1
2. Preferred treatment: Proactive and reactive therapy with TCS (low to high potency) or tacrolimus 1
3. Consider adjunctive therapies: Wet wrap therapy, antihistamines for itch relief 1

Specific Medications and Application

Topical Corticosteroids (TCS)

• First-line anti-inflammatory treatment for flares 1, 3
• Select potency based on severity, location, and patient age:
  • Infants should be treated with low-potency TCS due to increased risk of adrenal suppression 1
  • Avoid high-potency TCS on sensitive areas (face, neck, skin folds) 1
• Apply once or twice daily until significant improvement 1
• For moderate-severe AD, consider proactive therapy with twice-weekly application of low to medium potency TCS on previously affected areas 1

Topical Calcineurin Inhibitors (TCIs)

• Effective steroid-sparing agents for both acute and maintenance therapy 1
• Pimecrolimus 1% cream is approved for patients aged 3 months and above in Taiwan 1
• Tacrolimus 0.03% ointment is approved for patients aged 2 years and above 1
• Particularly useful for sensitive areas where TCS may cause atrophy 4
• Most common side effect: mild to moderate irritation (burning, erythema, pruritus) 4

Important Considerations and Pitfalls

Potential Pitfalls

1. Undertreatment: Fear of corticosteroid side effects ("steroid phobia") often leads to inadequate treatment 1
2. Overuse of potent steroids: Can cause skin atrophy, especially in infants 1, 5
3. Inconsistent moisturizer use: Regular application is essential, even when skin appears normal 2
4. Ignoring triggers: Failure to identify and avoid exacerbating factors 1

Special Considerations for Infants

• Infants are particularly susceptible to side effects from topical corticosteroids 5
• Diaper area typically spared in infantile atopic dermatitis 1
• Monitor closely for signs of secondary bacterial infection 2
• Avoid products containing preservatives, fragrances, or potential irritants 2

When to Consider Referral

• If there is diagnostic uncertainty
• When the condition fails to respond to first-line treatments
• For severe or widespread disease
• When considering dietary manipulation for suspected food allergies 2

By following this systematic approach to treating atopic dermatitis in infants, focusing first on skin barrier restoration with emollients and then adding appropriate anti-inflammatory therapy when needed, most cases can be effectively managed with good outcomes for both morbidity and quality of life.