What is the best treatment approach for a child with atopic dermatitis?

Treatment of Pediatric Atopic Dermatitis

All children with atopic dermatitis require daily fragrance-free emollient application (200-400g per week) as the foundation of therapy, with topical corticosteroid potency and treatment strategy determined by disease severity. 1, 2

Foundation Therapy (Required for All Patients)

Emollient Application

• Apply fragrance-free emollients liberally at least twice daily and as needed throughout the day to restore skin barrier function 1, 2, 3
• Ointments and creams are preferred for very dry skin or winter conditions 4
• Apply immediately after a 10-15 minute lukewarm bath when skin is most hydrated to maximize penetration 4, 1
• Regular emollient use provides both short-term and long-term steroid-sparing effects 4, 2

Trigger Avoidance

• Identify and eliminate exacerbating factors including dry skin, excessive sweating, temperature/humidity changes, irritants, allergens, infections, and stress 4
• Use cool environmental temperature, smooth cotton clothing, and avoid irritating fabrics like wool or synthetic fibers 4, 2
• Provide comprehensive caregiver education about proper skin care and the chronic, relapsing nature of the disease 4, 3

Severity-Based Treatment Algorithm

Mild Atopic Dermatitis

Definition: Only mild eruptions (mild erythema, dry skin, desquamation) regardless of body surface area 4

• Reactive therapy with low-potency topical corticosteroids (hydrocortisone 1%) applied once or twice daily to affected areas during flares until lesions significantly improve 1, 2, 3
• Continue emollient therapy throughout 1

Moderate Atopic Dermatitis

Definition: Severe eruptions (erythema, papules, erosion, infiltration, lichenification) in <10% of body surface area 4

• Proactive and reactive therapy with low to medium potency topical corticosteroids (fluticasone or mometasone) 1, 2
• During flares: Apply once or twice daily to affected areas 2
• After flare control: Transition to twice-weekly maintenance application to previously affected areas to prevent relapses 1, 2
• Alternative steroid-sparing option: Crisaborole (topical PDE-4 inhibitor) for patients ≥3 months old as an alternative to corticosteroids 1, 3

Severe to Very Severe Atopic Dermatitis

Definition: Severe eruptions in 10-29% (severe) or ≥30% (very severe) of body surface area 4

• Proactive and reactive therapy with medium to high potency topical corticosteroids for short periods (3-7 days maximum on the body) 1, 2
• Transition to twice-weekly proactive maintenance after flare control 1
• Add-on therapies:
  • Wet-wrap therapy with topical corticosteroids for 3-5 days as effective short-term second-line treatment 1
  • Oral antihistamines primarily for sedative properties to help with sleep disturbance during severe flares 1, 3
  • Dupilumab as first-line biologic for severe disease not responding to topical treatment 1

Location-Specific Guidance

Sensitive Areas (Face, Neck, Genital, Intertriginous)

• Use only low-potency corticosteroids (hydrocortisone 1%) to avoid skin atrophy 1, 2, 3
• Preferred alternative: Topical calcineurin inhibitors (tacrolimus 0.03% or pimecrolimus 1%) are particularly valuable for these areas 1, 2
• Important FDA restriction: Pimecrolimus is indicated as second-line therapy only for patients ≥2 years old who have failed to respond adequately to other topical prescription treatments 5
• Pimecrolimus showed 35% of patients clear or almost clear at 6 weeks versus 18% with vehicle in pediatric studies 5

Critical Safety Considerations

What NOT to Do

• Never use high-potency or ultra-high-potency topical corticosteroids in children due to increased risk of hypothalamic-pituitary-adrenal axis suppression, particularly with high body surface area involvement 1, 3
• Do not continue daily corticosteroid application beyond 7 days without reassessment—transition to proactive twice-weekly maintenance instead of abrupt discontinuation to prevent rebound flares 2
• Avoid long-term topical antibiotics due to increased resistance and skin sensitization risk 4, 1, 3
• Do not use topical antihistamines due to insufficient evidence for efficacy and increased risk of contact dermatitis 1
• Systemic corticosteroids should only be used for short-term crisis management due to risk of rebound flares upon discontinuation 1
• Phototherapy is not recommended for children younger than 12 years as long-term safety remains unclear 4, 1, 3

Managing Secondary Bacterial Infection

• Watch for crusting, weeping, or worsening despite treatment—these indicate secondary bacterial infection (usually Staphylococcus aureus) requiring oral antibiotics 2
• Flucloxacillin is the first-choice antibiotic for S. aureus infections 2

Common Pitfalls

• Applying topical corticosteroids as general moisturizers rather than targeting affected areas only 3
• Using high-potency steroids as first-line for moderate disease when low to medium potency is appropriate 2
• Neglecting basic emollient therapy which is essential regardless of disease severity 2, 3
• Failing to educate parents about the chronic, relapsing nature and proper skin care routine 3
• Poor treatment adherence—consider this if treatment response is inadequate before escalating therapy 2

Specialist Referral Indications

Refer to dermatology 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 advanced therapies (dupilumab, phototherapy in adolescents ≥12 years) in severe cases 4, 3