What is the recommended management for childhood atopic dermatitis?

Management of Childhood Atopic Dermatitis

All children with eczema should receive liberal emollient application (200-400g per week) at least twice daily plus low-potency topical corticosteroids for flares, with escalation to medium-potency steroids and topical calcineurin inhibitors only after optimizing this foundational approach. 1

Foundational Therapy for All Severities

Emollient Application

• Apply fragrance-free emollients liberally at least twice daily to all skin, not just affected areas, as this provides both short-term and long-term steroid-sparing effects 2, 1, 3
• Use 200-400g per week to maintain adequate skin barrier function 1
• Apply immediately after a 10-15 minute lukewarm bath when skin is most hydrated 2, 1
• Ointments and creams are preferred over lotions for very dry skin 2

Bathing Practices

• Bathe for 10-15 minutes in lukewarm water using gentle, soap-free cleansers 2, 3
• Apply emollient within 3 minutes after bathing to lock in moisture 3
• Avoid emollient bath additives—they provide no clinical benefit and waste resources 4
• For moderate-to-severe disease, twice-daily "soak-and-seal" baths (15-20 minutes followed by immediate moisturizer application) are superior to twice-weekly bathing 5

Trigger Avoidance

• Identify and eliminate specific triggers including irritants, allergens, excessive sweating, temperature/humidity changes, and stress 2, 3
• Use cotton clothing next to skin and avoid wool or synthetic fabrics 1
• Keep environmental temperature cool and use smooth, non-irritating clothing 2

Severity-Based Topical Corticosteroid Algorithm

Mild Eczema

• Use reactive therapy only with hydrocortisone 1% (low-potency) applied once or twice daily to affected areas during flares 1, 3
• Continue until lesions significantly improve, typically within 3-7 days 1
• Apply no more than twice daily; once-daily dosing may be sufficient with newer formulations 3

Moderate Eczema

• Use both reactive and proactive therapy with low to medium-potency topical corticosteroids (fluticasone or mometasone) 1, 3
• During active flares: apply once or twice daily until controlled 3
• After flare resolution: transition to twice-weekly proactive maintenance on previously affected areas for up to 16 weeks to prevent relapses 1, 3
• This proactive approach reduces subsequent flares seven-fold compared to emollient alone 6

Severe to Very Severe Eczema

• Use medium to high-potency topical corticosteroids (e.g., betamethasone dipropionate) for short periods (3-7 days maximum) on the body 2, 1
• High-potency steroids achieve 94% good-to-excellent response in severe disease 6
• Critical pitfall: Do not continue daily corticosteroid application beyond 7 days without reassessment—transition to twice-weekly maintenance instead of abrupt discontinuation to prevent rebound flares 1

Location-Specific Guidance

• Face, neck, and skin folds: Use only hydrocortisone 1% (low-potency) to avoid skin atrophy 2, 1
• Consider topical calcineurin inhibitors as alternatives for these sensitive areas 2, 1

Age-Specific Precautions

• Infants (<2 years): Use only hydrocortisone 1% due to high body surface area-to-volume ratio and increased risk of hypothalamic-pituitary-adrenal axis suppression 3
• Children (2-12 years): Low to medium-potency topical corticosteroids as first-line 3
• Adolescents (>12 years): Medium to high-potency topical corticosteroids as needed 3

Second-Line Therapy: Topical Calcineurin Inhibitors

Before initiating topical calcineurin inhibitors, confirm that the potency of the topical corticosteroid used is adequate—low-potency steroids may be insufficient for moderate disease. 6

Indications

• Children ≥2 years with atopic dermatitis inadequately controlled by appropriate-strength topical corticosteroids and emollients 2, 6
• Particularly valuable for facial and intertriginous areas where corticosteroid side effects are concerning 2, 3

Medication Selection

• Tacrolimus 0.03% ointment: For mild-to-moderate disease in patients ≥2 years 2, 6
• Tacrolimus 0.1% ointment: For moderate-to-severe disease in patients ≥2 years 2, 6
• Pimecrolimus 1% cream: For patients ≥2 years; FDA-approved with 35% of patients achieving clear or almost clear skin at 6 weeks versus 18% with vehicle 2, 6, 7

Safety Profile

• The risk-benefit ratio is comparable to most conventional therapies for chronic relapsing eczema 6
• Observed incidence of lymphoma is lower than predicted for the general population 6
• Contraindications: Do not use in children <2 years, immunocompromised patients, with concurrent phototherapy, or in severely impaired skin barrier (e.g., Netherton syndrome) 6

Alternative Second-Line Option: Wet-Wrap Therapy

• For moderate to very severe AD when topical calcineurin inhibitors are unsuitable or unavailable 2, 3
• Apply topical corticosteroid, cover with wet tubular bandage layer, then add dry layer on top 2, 3
• Use for 3-7 days (maximum 14 days) 3
• Requires specialized instruction and often dermatology referral 3

Managing Complications

Secondary Bacterial Infection

• Watch for crusting, weeping, or worsening despite treatment—these indicate Staphylococcus aureus infection requiring oral antibiotics 2, 1
• First-line antibiotic: Flucloxacillin for S. aureus 1, 3
• For β-hemolytic streptococcal infection: phenoxymethylpenicillin 3
• For penicillin allergy: erythromycin 3
• Avoid long-term topical antibiotics due to resistance risk and skin sensitization 3

Eczema Herpeticum

• Initiate oral acyclovir promptly 3
• If patient is ill and febrile, administer intravenous acyclovir 3

Adjunctive Therapies

Antihistamines

• Sedating antihistamines may help short-term for sleep disturbance caused by severe pruritus, primarily at night 2, 1, 3
• Non-sedating antihistamines offer little therapeutic benefit for itch control 3

Ineffective Therapies to Avoid

• Elimination diets: Should not be employed as next therapeutic step after topical therapy failure; only indicated when history strongly suggests specific food allergy 6
• Evening primrose oil and borage oil: Two large trials showed no benefit 1
• Homeopathic remedies: Lack scientific evidence 1
• Probiotics and vitamin D: Have yet to demonstrate convincing benefits 2

Systemic Therapy Considerations

Systemic corticosteroids should be avoided in pediatric AD except for short-term crisis management (≤2 weeks) due to rebound flares and hypothalamic-pituitary-adrenal axis suppression. 2, 3, 6

Dupilumab (Biologic Therapy)

• FDA-approved for moderate-to-severe atopic dermatitis in patients ≥6 months whose disease is not adequately controlled with topical prescription therapies 8
• Can be used with or without topical corticosteroids 8
• Reserved for cases failing optimized topical therapy, including topical calcineurin inhibitors 6

Before Initiating Any Systemic Treatment

• Optimize topical therapy first 6
• Ensure thorough patient/caregiver education 6
• Rule out secondary bacterial colonization 6
• Evaluate phototherapy as an alternative option 6

Referral Criteria

Refer to dermatology or allergy/immunology when:

• Disease worsens despite appropriate escalation to topical calcineurin inhibitors 3, 6
• Wet-wrap therapy is being considered (requires specialized instruction) 3
• Secondary infection persists despite standard management 2, 3
• Systemic immunosuppressive therapy becomes necessary 2, 6
• Poor treatment adherence or alternative diagnoses need evaluation 2

Patient Education Priorities

• Comprehensive education reduces disease severity and improves quality of life 2
• Educate about the chronic, relapsing nature of atopic dermatitis 3
• Address steroid phobia by explaining relative potencies, benefits, and risks to improve adherence 3
• Emphasize that maintaining skin barrier integrity with emollients is essential regardless of disease severity or presence of active lesions 3