What are the management options for a 4-year-old with worsening pityriasis alba and atopic dermatitis, previously treated with Elidel (pimecrolimus) for 4 weeks?

From the Guidelines

For a 4-year-old with worsening pityriasis alba and atopic dermatitis, I strongly recommend discontinuing Elidel (pimecrolimus) and initiating a treatment regimen that prioritizes controlling the underlying atopic dermatitis. The most recent and highest quality study, 1, suggests that for most people with atopic dermatitis, emollients and prescription topical therapies are sufficient to achieve disease control. Given this, I recommend using a low-potency topical corticosteroid such as hydrocortisone 1% cream twice daily for 7-10 days on affected areas to reduce inflammation, as supported by the guidelines for managing atopic dermatitis in adults with phototherapy and systemic therapies 1. It's also crucial to follow with a gentle moisturizer like CeraVe or Vanicream applied liberally at least twice daily to the entire body, including the hypopigmented areas. Sun protection is essential - use a pediatric-friendly SPF 30+ sunscreen daily on exposed areas, as sun exposure can worsen the contrast between normal and hypopigmented skin. For bathing, use lukewarm water for no more than 10 minutes with a gentle, fragrance-free cleanser, and apply moisturizer immediately after patting dry. Avoid known irritants including harsh soaps, fragrances, and rough fabrics. The goal is to control the underlying atopic dermatitis, which should eventually lead to improvement in the hypopigmented patches. If no improvement occurs within 4 weeks of this regimen, consider referral to a pediatric dermatologist for evaluation of other potential diagnoses or treatment options, taking into account the severity of the condition, its impact on the patient, and the efficacy, safety, and accessibility of available interventions, as recommended by 1. It's worth noting that while the study 1 focuses on adults, the principles of managing atopic dermatitis can be applied to children, with adjustments for age and sensitivity. In contrast to older guidelines like 1, the newer recommendations provide stronger evidence for the use of certain therapies, emphasizing the importance of staying updated with the latest clinical practice guidelines. Ultimately, the decision to initiate more advanced therapies should be made using shared decision-making between patients and clinicians, considering the individual case and the most current evidence available.

From the FDA Drug Label

The patient or care giver should apply a thin layer of ELIDEL (pimecrolimus) Cream 1% to the affected skin twice daily. The patient or caregiver should stop using when signs and symptoms (e.g., itch, rash and redness) resolve and should be instructed on what actions to take if symptoms recur. If signs and symptoms persist beyond 6 weeks, patients should be re-examined by their health care provider to confirm the diagnosis of atopic dermatitis. Continuous long-term use of ELIDEL Cream should be avoided, and application should be limited to areas of involvement with atopic dermatitis. A patient should not use ELIDEL Cream continuously for a long time. ELIDEL Cream should be used only on areas of skin that have eczema. A patient should use ELIDEL Cream for short periods, and if needed, treatment may be repeated with breaks in between.

The patient has been using ELIDEL for 4 weeks and the symptoms have worsened. Management options include:

• Stopping ELIDEL Cream as the symptoms have not improved after 4 weeks of treatment and the hypopigmentation lesions have worsened 2
• Re-examining the patient to confirm the diagnosis of atopic dermatitis and considering alternative treatments 2
• Using ELIDEL Cream for short periods, with breaks in between, as continuous long-term use should be avoided 2

From the Research

Management Options for Pityriasis Alba and Atopic Dermatitis

• The patient's condition has worsened despite initial management with Elidel (pimecrolimus cream 1%) for 4 weeks, with hypopigmentation lesions becoming more widespread on the face and atopic dermatitis persisting 3, 4.
• Pimecrolimus cream 1% has been shown to be effective in managing atopic eczema and pityriasis alba, with anti-inflammatory properties and minimal risk of skin atrophy, making it a suitable alternative to topical corticosteroids, especially for delicate skin areas like the face 3, 4, 5.
• Studies have demonstrated the efficacy and safety of pimecrolimus cream 1% in infants and children with atopic dermatitis, with significant reductions in disease flares and improvements in overall disease control and quality of life 6, 7.
• The use of pimecrolimus cream 1% may be beneficial in preventing disease flares and improving long-term outcomes in patients with atopic dermatitis, with a steroid-sparing effect and minimal risk of adverse events 6, 7.

Treatment Considerations

• The patient's treatment plan may need to be revised to address the worsening of hypopigmentation lesions and atopic dermatitis, potentially involving the continued use of pimecrolimus cream 1% or the addition of other therapies 4, 7.
• The safety and efficacy of pimecrolimus cream 1% in the long-term management of atopic dermatitis and pityriasis alba have been established, making it a viable option for ongoing treatment 6, 7, 5.
• Regular monitoring of the patient's condition and adjustments to the treatment plan as needed may be necessary to achieve optimal disease control and minimize the risk of adverse events 3, 4, 6, 7, 5.