In a child with persistent atopic dermatitis despite adequate emollient use and appropriate‑strength topical corticosteroids, what is the best next step in management?

Best Next Step: Topical Calcineurin Inhibitors

For a child with atopic dermatitis inadequately controlled by appropriate-strength topical corticosteroids and emollients, the best next step is to start topical calcineurin inhibitors (tacrolimus or pimecrolimus). 1

Rationale for This Recommendation

The Taiwan Academy of Pediatric Allergy, Asthma and Immunology explicitly positions topical calcineurin inhibitors (TCIs) as steroid-sparing immunomodulators for children aged 2 years and above when conventional topical therapy fails. 1 Wet-wrap therapy should be considered as a treatment option ahead of systemic immunosuppressive therapies for patients failing conventional topical therapy. 1 This creates a clear treatment hierarchy: optimize topical steroids → add TCIs or wet-wrap therapy → only then consider systemic options.

Why Not the Other Options?

Systemic corticosteroids (Option B) should be avoided because they carry significant risks in children, including rebound flares upon discontinuation, HPA axis suppression, and are only appropriate for short-term crisis management (typically 2 weeks in tapering doses). 2, 3 The guidelines consistently recommend against long-term systemic corticosteroid use in pediatric AD. 1, 4

Elimination diets (Option A) are not the next step in management when topical therapy has failed. While trigger identification is important, dietary manipulation is not positioned as a second-line therapy in the treatment algorithm. 1 The focus should remain on escalating anti-inflammatory topical therapy before considering dietary interventions.

Practical Implementation

Topical Calcineurin Inhibitor Selection

• Tacrolimus ointment is available in 0.03% and 0.1% concentrations for children ≥2 years old 1
• Pimecrolimus cream 1% is also approved for children ≥2 years old 1, 5
• Both agents are particularly valuable for facial and intertriginous areas where corticosteroid side effects (skin atrophy) are most concerning 6

Dosing and Application

Apply a thin layer twice daily to affected skin areas. 5 Patients should stop using TCIs when signs and symptoms (itch, rash, redness) resolve. 5 If symptoms persist beyond 6 weeks, re-examine the patient to confirm the diagnosis. 5 Continuous long-term use should be avoided, and application should be limited to areas of active involvement. 5

Alternative Second-Line Option: Wet-Wrap Therapy

If TCIs are not suitable or available, wet-wrap therapy with topical corticosteroids is an effective and relatively safe short-term second-line treatment for moderate to very severe AD. 1 This involves applying topical corticosteroid, covering with a wet layer of tubular bandages, then a dry layer on top for 3-7 days (maximum 14 days in severe cases). 1, 6 However, this requires specialized instruction and often necessitates dermatology referral. 6

Safety Considerations

Black Box Warning Context

The American College of Allergy, Asthma and Immunology and the American Academy of Allergy, Asthma and Immunology concluded that the risk/benefit ratios of topical pimecrolimus and tacrolimus are similar to those of most conventional therapies for chronic relapsing eczema. 1 The actual rate of lymphoma formation reported for topical calcineurin inhibitors is lower than predicted in the general population. 1

Contraindications and Precautions

• Do not use in children younger than 2 years of age 1
• Avoid in patients with compromised immune systems 1
• Do not use with concurrent phototherapy 1
• Avoid in patients with severely impaired skin barrier function (e.g., Netherton syndrome) that might result in immunosuppressive blood levels 1
• Do not use with occlusive dressings 5

When to Refer to Specialist

Consider dermatology or allergy/immunology referral if:

• Disease worsens despite appropriate escalation to TCIs 6
• Wet-wrap therapy is being considered (requires specialized instruction) 6
• Signs of secondary infection not responding to treatment 6
• Consideration of systemic therapies becomes necessary 1

Maintaining Foundational Therapy

Continue liberal and regular emollient use regardless of adding TCIs, as emollients provide both short- and long-term steroid-sparing effects. 1, 6 Continue trigger identification and avoidance strategies. 1, 6