What is the diagnosis and treatment for Atopic Dermatitis (AD) in a 1-year-old boy?

Diagnosis and Treatment of Atopic Dermatitis in a 1-Year-Old Boy

Atopic dermatitis in a 1-year-old boy is diagnosed based on clinical features including intense pruritus, eczematous lesions with symmetrical distribution, chronic/relapsing course, and family history of atopy, and is best treated with a combination of regular emollient application and low-potency topical corticosteroids for flares. 1, 2

Diagnosis

Clinical Features for Diagnosis

• Diagnosis is primarily clinical, based on characteristic features including intense pruritus, eczematous lesions, chronic/relapsing disease course, and personal or family history of atopy 1
• Eczematous lesions typically display symmetrical and age-specific distribution pattern in infants (commonly affecting cheeks, scalp, extensor surfaces of extremities) 1
• Approximately 80% of patients with atopic dermatitis develop symptoms within the first 5 years of life 1
• Other conditions that may mimic atopic dermatitis should be ruled out, including infectious diseases, primary immunodeficiencies, nutritional deficiencies, or skin malignancies 1

Severity Assessment

• Mild: Only mild eruptions (mild erythema, dry skin, or desquamation) regardless of body surface area involvement 1
• Moderate: Severe eruptions (erythema, papules, erosion, infiltration, or lichenification) in <10% of body surface area 1
• Severe: Severe eruptions in 10-29% of body surface area 1
• Very severe: Severe eruptions in ≥30% of body surface area 1

Treatment Approach

Basic Therapy (For All Severity Levels)

• Apply fragrance-free emollients regularly to maintain skin barrier integrity, which is essential for all infants with atopic dermatitis regardless of disease severity 3, 2
• Use lukewarm water (10-15 minutes) with gentle, soap-free cleansers, followed immediately by application of emollients to lock in moisture 3, 2
• Identify and eliminate potential triggers such as irritants, allergens, excessive sweating, changes in temperature or humidity, and stress 1, 2
• Provide comprehensive education to parents about proper skin care routine and the chronic, relapsing nature of atopic dermatitis 2

Topical Anti-inflammatory Treatment

• For mild to moderate flares, use low-potency topical corticosteroids (such as 1% hydrocortisone) 2, 4
• Apply a thin layer of topical corticosteroid to affected areas only, not as a general moisturizer 2
• For infants, limit application to 3-4 times daily as directed by the FDA label 4
• Avoid high-potency corticosteroids in infants due to increased risk of adrenal suppression 1, 2
• For sensitive areas (face, neck, skin folds), use low-potency corticosteroids with caution to avoid skin atrophy 1, 2

Stepwise Treatment Based on Severity

Mild Atopic Dermatitis

• Basic therapy with emollients and trigger avoidance 3, 2
• Reactive therapy with low-potency topical corticosteroids during flares 3, 2

Moderate Atopic Dermatitis

• Basic therapy with emollients and trigger avoidance 3, 2
• Proactive and reactive therapy with low-potency topical corticosteroids 3, 2
• Consider topical PDE-4 inhibitor (crisaborole) for patients aged 3 months and above as an alternative to corticosteroids 2, 1

Severe to Very Severe Atopic Dermatitis

• Basic therapy with emollients and trigger avoidance 3, 2
• Proactive and reactive therapy with low to medium potency topical corticosteroids 3, 2
• Consider wet-wrap therapy with topical corticosteroids for short periods (3-7 days, maximum 14 days) 1, 2
• Oral antihistamines may be used as adjuvant therapy primarily for their sedative properties to help with sleep disturbance during severe flares 1, 2

Important Considerations and Precautions

• Long-term application of topical antibiotics is not recommended due to increased risk of resistance and skin sensitization 1, 2
• Topical calcineurin inhibitors are not approved for infants under 2 years old 2
• Topical PDE-4 inhibitors (crisaborole) have been approved for patients aged 3 months and above for mild to moderate atopic dermatitis 1, 2
• Phototherapy is not recommended for children younger than 12 years as long-term safety remains unclear 1, 3
• Consider referral to a specialist if the condition worsens despite appropriate first-line management, if there are signs of suspected secondary infection not responding to treatment, or for consideration of more advanced therapies in severe cases 2, 5

Common Pitfalls to Avoid

• Using high-potency topical corticosteroids in infants, which increases risk of adrenal suppression 1, 2
• Applying topical corticosteroids as general moisturizers rather than targeting affected areas only 2
• Neglecting basic therapy with regular emollient application, which is essential regardless of disease severity 3, 2
• Long-term use of topical antibiotics, which increases risk of resistance and skin sensitization 1, 2
• Failing to educate parents about the chronic, relapsing nature of atopic dermatitis and proper skin care routine 2, 6