How to manage recurrent scalp dermatitis in children that is resistant to topical treatment?

Management of Recurrent Scalp Dermatitis Resistant to Topical Treatment in Children

For children with recurrent scalp dermatitis resistant to topical treatments, wet-wrap therapy with topical corticosteroids is recommended as an effective and relatively safe short-term second-line treatment option before considering systemic therapies. 1

Step-Up Approach for Treatment-Resistant Scalp Dermatitis

First-Line Options to Reconsider

• Ensure proper use of low to medium potency topical corticosteroids (TCSs), which remain the first-line treatment for inflammatory skin conditions 1
• For facial and intertriginous areas, topical calcineurin inhibitors (TCIs) are preferred to avoid skin atrophy 1, 2
• Regular use of emollients has both short and long-term steroid-sparing effects in mild to moderate dermatitis 1

Second-Line Options for Treatment Resistance

• Wet-wrap therapy with TCSs:

  • Serves as an effective barrier against scratching 1
  • Promotes trans-epidermal penetration of TCSs 1
  • Recommended for 3-7 days, with possible extension to 14 days in severe cases 1
  • Should be considered before moving to systemic immunosuppressive therapies 1

• Topical calcineurin inhibitors (if not already tried):

  • Tacrolimus ointment 0.03% for children aged 2 years and above 1, 2
  • Pimecrolimus cream 1% for children aged 2 years and above 1, 2
  • Particularly useful for steroid-resistant cases and as steroid-sparing agents 1

• Rotational therapy:

  • Alternating between topical vitamin D analogues, TCIs, emollients, tar-based therapies, and TCSs 1
  • Serves as a steroid-sparing regimen to reduce potential adverse effects from overreliance on topical steroid therapy 1

Third-Line Options

• Oral antihistamines:

  • Recommended as adjuvant therapy for reducing pruritus 1
  • Most effective value is in their sedative properties for severe itching 1
  • Non-sedating antihistamines have little value in atopic dermatitis 1

• Systemic treatments for very severe cases:

  • Immunomodulators (cyclosporin, azathioprine, methotrexate) may be used in children with very severe dermatitis resistant to other treatments 1, 3
  • Dupilumab for severe to very severe dermatitis refractory to conventional treatment in children 6 years and above 1
  • Short-term oral corticosteroids (<7 days) may be considered when clinically necessary, but long-term use is not recommended due to adverse effects 1, 4

Special Considerations for Scalp Dermatitis

• For seborrheic dermatitis of the scalp:

  • Low-potency topical corticosteroids for short-term control (less than 7 days) 2
  • Topical antifungals may be beneficial but monitor for irritation 2

• For atopic dermatitis of the scalp:

  • Combination of calcipotriol/betamethasone dipropionate suspension applied once daily for up to 8 weeks may be effective for children 12 years and older 1
  • Monitor for potential side effects such as mild HPA suppression 1

Important Cautions

• Infants and young children should be treated with less potent TCSs due to increased risk of adrenal suppression 1
• Long-term application of topical antibiotics is not recommended due to increased risk of resistance and sensitization 1
• Topical antihistamines might increase the risk of contact dermatitis and are generally not recommended 1
• Consider bacterial infection if there is poor response to treatment; use systemic antibiotics only when there is clinical evidence of infection 1

Monitoring and Follow-up

• If using calcipotriene/calcipotriol on large body surface areas, monitor vitamin D metabolites 1
• For children using potent TCSs, monitor for signs of skin atrophy and HPA axis suppression 4
• Consider poor treatment adherence if response is inadequate 1
• Evaluate for other diagnoses if treatment response remains poor despite appropriate therapy 1