What is the recommended treatment for atopic dermatitis in pediatric patients?

Treatment of Atopic Dermatitis in Pediatric Patients

All pediatric patients with atopic dermatitis should receive regular application of fragrance-free emollients as foundational therapy, with severity-based escalation to topical corticosteroids as first-line anti-inflammatory treatment, using low-potency agents (hydrocortisone 1%) for infants and mild disease, and medium-potency agents for moderate-to-severe cases. 1, 2, 3

Foundational Therapy (All Patients, All Severities)

• Apply fragrance-free emollients liberally and regularly to maintain skin barrier integrity, regardless of disease severity or presence of active lesions 1, 3
• Use lukewarm baths (10-15 minutes) with gentle, soap-free cleansers, followed immediately by emollient application to lock in moisture 3
• Identify and eliminate specific triggers including irritants, allergens, excessive sweating, temperature/humidity changes, and stress 1, 3
• Provide comprehensive caregiver education about proper skin care routines and the chronic, relapsing nature of atopic dermatitis 1, 3

Severity-Based Treatment Algorithm

Mild Atopic Dermatitis

• Use reactive therapy with low-potency topical corticosteroids (hydrocortisone 1%) during flares only 1, 3
• Apply a thin film once or twice daily to affected areas for 3-7 days, not as a general moisturizer 2, 3
• Continue emollient therapy between flares 1

Moderate Atopic Dermatitis

• Implement both proactive and reactive therapy with low to medium-potency topical corticosteroids 1, 3
• Apply twice-weekly to previously affected areas to prevent relapses (proactive approach) 1, 3
• Use reactive treatment during active flares as described above 1
• Consider topical PDE-4 inhibitor (crisaborole) as an alternative for patients ≥3 months old 3
• Topical calcineurin inhibitors (tacrolimus 0.1% or pimecrolimus) can be used for patients ≥2 years, particularly for face and genital regions 4, 5, 6

Severe to Very Severe Atopic Dermatitis

• Use proactive and reactive therapy with medium to high-potency topical corticosteroids 1, 3
• Add wet-wrap therapy with topical corticosteroids for short-term use during severe exacerbations 1, 3
• Consider oral antihistamines primarily for their sedative properties to address sleep disturbance from severe pruritus 1, 3
• For patients ≥6 months with refractory disease, dupilumab is an effective biologic option 1, 7
• In resource-limited settings where biologics are unavailable, cyclosporine remains first-line systemic therapy for severe refractory cases 7

Age-Specific Considerations

Infants (<2 years)

• Use only low-potency topical corticosteroids (hydrocortisone 1%) due to high body surface area-to-volume ratio and increased risk of HPA axis suppression 2, 3
• Avoid high-potency or ultra-high-potency topical corticosteroids entirely in this age group 2
• Pimecrolimus may be used in infants as young as 3 months, though topical calcineurin inhibitors are not FDA-approved for infants under 2 years 3, 5, 6
• Limit duration of topical corticosteroid exposure on sensitive areas (face, neck, skin folds) to prevent skin atrophy 2, 3

Children (2-12 years)

• Low to medium-potency topical corticosteroids are appropriate first-line therapy 1, 7
• Topical calcineurin inhibitors (tacrolimus 0.1%, pimecrolimus) and topical PDE-4 inhibitors (crisaborole) have sufficient safety data for use in this age group 3, 6
• Oral systemic immunosuppressants can be used for refractory disease not responding to topical treatments 6

Adolescents (>12 years)

• Medium to high-potency topical corticosteroids can be used as needed 1
• Dupilumab is FDA-approved and represents an effective biologic option for moderate-to-severe disease 6, 7
• JAK inhibitors (upadacitinib, abrocitinib) show high efficacy in rapidly reducing severity scores, though cost may limit accessibility 7
• Phototherapy may be utilized if accessible, though it is not recommended for children younger than 12 years 1, 6

Critical Safety Precautions

• Avoid long-term application of topical antibiotics due to increased resistance risk and skin sensitization; use only when clinical evidence of bacterial infection exists 1, 3
• Systemic corticosteroids should be used only for short periods (typically 2 weeks in tapering doses) in severe acute exacerbations due to risk of rebound flares upon discontinuation 1, 7
• Monitor infants and young children closely for signs of HPA axis suppression, skin atrophy, and striae when using topical corticosteroids 2, 3
• Provide careful instruction to caregivers on the amount to apply, safe sites for use, and supply limited quantities to prevent overuse 4, 2
• Transition gradually from high-potency corticosteroids to appropriate alternative treatments to avoid rebound flares 4

When to Refer to Specialist

• Disease worsens despite appropriate first-line management with emollients and low-potency topical corticosteroids 3
• Signs of suspected secondary infection (bacterial or eczema herpeticum) not responding to treatment 2, 3
• Consideration needed for advanced therapies including biologics, JAK inhibitors, or systemic immunosuppressants in severe refractory cases 3, 7