Treatment of Pediatric Atopic Dermatitis
The recommended treatment for pediatric atopic dermatitis follows a stepwise approach, with basic therapy consisting of emollients and trigger avoidance as the foundation, followed by topical corticosteroids as first-line medication for all severity levels, with additional therapies added based on disease severity and response. 1
Basic Therapy (For All Severity Levels)
- Regular application of fragrance-free emollients is essential for maintaining skin barrier integrity in all children with atopic dermatitis 1
- Lukewarm baths (10-15 minutes) with gentle, soap-free cleansers followed immediately by emollient application help maintain skin hydration 1
- Identification and avoidance of triggers such as allergens, irritants, excessive sweating, and environmental factors is crucial for management 2, 1
- Comprehensive education for caregivers about proper skin care and the chronic, relapsing nature of atopic dermatitis improves outcomes 2
Stepwise Treatment Based on Severity
Mild Atopic Dermatitis
- Preferred treatment: Reactive therapy with low-potency topical corticosteroids (TCS) during flares 2, 1
- Alternative options: Topical calcineurin inhibitors (TCIs) like pimecrolimus or topical PDE-4 inhibitors (crisaborole) for patients ≥3 months of age 2, 3
- Pimecrolimus has been shown to be effective in children as young as 3 months with mild to moderate atopic dermatitis 3
Moderate Atopic Dermatitis
- Preferred treatment: Proactive and reactive therapy with low to medium potency TCS 2, 1
- Alternative options:
- Proactive therapy with twice-weekly application of TCS or TCIs to previously affected areas helps prevent relapses 2
Severe to Very Severe Atopic Dermatitis
- Preferred treatment: Proactive and reactive therapy with medium to high potency TCS 2, 1
- Add-on therapies:
- Wet-wrap therapy with TCS for short-term use in moderate to very severe cases 2
- Oral antihistamines as adjuvant therapy for reducing pruritus 2
- For refractory cases: Dupilumab (approved for ≥6 years in Taiwan) 2
- For very severe cases: Immunomodulators (cyclosporin, methotrexate, azathioprine) may be considered as off-label use 2, 4
Important Considerations and Precautions
- Low-potency TCS should be used for sensitive areas (face, neck, skin folds) and in infants to avoid skin atrophy 1, 5
- Long-term application of topical antibiotics is not recommended due to increased risk of resistance and skin sensitization 2
- Topical antihistamines are not recommended due to increased risk of contact dermatitis 2
- Systemic corticosteroids should be used only for short periods (<7 days) in severe acute exacerbations due to risk of rebound flares upon discontinuation 2
- Phototherapy is not recommended for children younger than 12 years as long-term safety remains unclear 2
Age-Specific Considerations
Infants (<2 years)
- Use low-potency TCS as first-line medication-based therapy 1, 6
- Pimecrolimus can be used in infants as young as 3 months 3, 6
- Extra caution with TCS due to increased risk of adrenal suppression from higher body surface area to volume ratio 1
Children (2-12 years)
- Low to medium potency TCS are first-line therapies 2, 6
- TCIs and PDE-4 inhibitors can be used as steroid-sparing agents 2, 6
- For severe cases unresponsive to topical therapy, consider systemic immunosuppressants 6, 4
Adolescents (>12 years)
- Similar approach as for children, with additional options including phototherapy and biologics like dupilumab for severe cases 6
Efficacy of Treatment Options
- Studies show that 0.03% tacrolimus ointment is significantly more efficacious than 1% hydrocortisone acetate in treating moderate-severe atopic dermatitis in children 7
- Twice daily application of 0.03% tacrolimus ointment results in greater improvement, especially in patients with severe disease 7
- Pimecrolimus has demonstrated efficacy in clinical trials, with 35% of treated patients becoming clear or almost clear of signs compared to 18% with vehicle 3