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

Presentation and First-Line Treatment of Atopic Dermatitis in Children

Moisturizers with fragrance-free emollients are the first-line therapy for all children with atopic dermatitis, regardless of severity, combined with low-potency topical corticosteroids for active flares. 1, 2

Clinical Presentation

Age-Specific Distribution Patterns

Infancy (typically starting before 5 years of age):

• Eczema usually begins on the cheeks and progressively extends to the neck, trunk, and extensor surfaces of extremities 1
• Notable sparing of the diaper area is characteristic 1
• Approximately 80% of patients develop symptoms within the first 5 years of life 1

Childhood and Adolescence:

• Lesions become more localized and chronic 1
• Skin involvement commonly affects flexor surfaces of extremities 1
• Symmetrical distribution pattern is typical 1

Lesion Characteristics

Acute lesions present with:

• Erythema, exudation, papules, and vesiculopapules 1

Chronic lesions present with:

• Lichenification, prurigo, scales, and crusts 1

Diagnostic Criteria

All three essential criteria must be present:

1. Pruritus with symmetrical and age-specific distribution patterns 1
2. Eczematous lesions as described above 1
3. Chronic or relapsing course (>2 months in infancy; >6 months in childhood/adolescence) 1

First-Line Treatment Algorithm

Universal Basic Therapy (All Severity Levels)

Emollient therapy is mandatory for every patient:

• Apply fragrance-free emollients frequently throughout the day to restore skin barrier function 1, 2, 3
• Optimal timing is immediately after a 10-15 minute lukewarm bath or shower 1, 3
• Regular emollient use has both short- and long-term steroid-sparing effects in mild to moderate disease 1

Environmental modifications:

• Maintain cool environmental temperature and use smooth, non-irritating clothing 1
• Avoid irritating fabrics, fibers, excessive sweating, and temperature/humidity changes 1, 3
• Use gentle, soap-free cleansers during bathing 2, 3

Severity-Based Topical Corticosteroid Approach

Mild atopic dermatitis (mild erythema, dry skin, or desquamation only):

• Reactive therapy with low-potency topical corticosteroids (such as 1% hydrocortisone) during flares 2, 3
• Continue emollient therapy as the foundation 2, 3

Moderate atopic dermatitis (severe eruptions in <10% body surface area):

• Proactive and reactive therapy with low to medium-potency topical corticosteroids 2, 3
• Proactive therapy involves twice-weekly application to previously affected areas to prevent relapses 2, 3
• Topical PDE-4 inhibitor (crisaborole) may be considered as an alternative in infants ≥3 months 3

Severe to very severe atopic dermatitis (severe eruptions in ≥10% body surface area):

• Proactive and reactive therapy with medium to high-potency topical corticosteroids 2
• Add wet-wrap therapy with topical corticosteroids for short-term use during severe flares 2, 3
• Consider oral antihistamines primarily for their sedative properties to address sleep disturbance from pruritus 2, 3

Critical Safety Considerations

Topical corticosteroid precautions:

• Use low-potency formulations for sensitive areas (face, neck, skin folds) and in infants to avoid skin atrophy 2, 3
• Infants have increased risk of adrenal suppression due to higher surface area-to-volume ratio and slower drug metabolism 3, 4
• Apply as a thin layer to affected areas only, not as a general moisturizer 3

Age-specific medication restrictions:

• Topical calcineurin inhibitors (pimecrolimus, tacrolimus) are not approved for infants under 2 years old 3
• Pimecrolimus may be used in infants as young as 3 months according to some guidelines 5
• Topical PDE-4 inhibitors (crisaborole) are approved for patients aged 3 months and above 3

Treatments to avoid:

• Long-term topical antibiotics increase resistance and skin sensitization risk; use only with clinical evidence of bacterial infection 2, 3
• Systemic corticosteroids should be reserved for short periods in severe acute exacerbations due to rebound flare risk upon discontinuation 2
• Phototherapy is not recommended for children younger than 12 years due to unclear long-term safety 2

When to Escalate or Refer

Consider specialist referral when:

• Condition worsens despite appropriate first-line management with emollients and topical corticosteroids 3
• Signs of secondary infection not responding to treatment 3
• Severe cases requiring consideration of dupilumab (for refractory cases), systemic immunosuppressants, or phototherapy 2, 5, 6