Address the 4 aspects of the disease simultaneously and refer to the treatment algorithm for stepwise therapeutic choices.

Treating children with atopic dermatitis involves addressing 4 aspects of the disease simultaneously. Treatment choices are considered in a stepwise manner and depend on the severity of the disease. Refer to the Treatment Toolfor a summative view of treatment options.

The treatment of atopic dermatitis includes the following simultaneous measures:

1. Moisturizing the skin, for the purpose of
   1. Repairing and maintaining the skin barrier
   2. Hydrating the skin (which can prevent pruritus)
2. Reducing itch
3. Treating inflammation
4. Preventing and managing skin infections

These treatment targets, when effectively addressed, not only improve disease symptoms and reduce flares but assist the child and family in achieving adequate sleep.

Parents should be encouraged to establish healthy sleep routines as part of the treatment plan. Adequate sleep is necessary for optimal growth and development, promotes mental health, and improves quality of life for the patient and family.

Read More about Healthy Sleep

Treatment Targets

Moisturizing the Skin

Moisturizers (emollients) are the cornerstone of atopic dermatitis treatment. They are the main treatment for mild atopic dermatitis and an important part of treating moderate to severe atopic dermatitis.

Apply an emollient as needed to control dry skin (xerosis). The most effective timing is immediately after bathing (while the skin is still moist). Application often is recommended at least once daily, but this varies with the individual and environmental factors (eg, during warm weather months in humid conditions an emollient may not be needed).

• Lotions (eg, CeraVe, Cetaphil, Curel, Eucerin, Lubriderm, Moisturel, Aveeno) work well for most individuals, although preservatives (found in some) occasionally cause stinging or skin reactions.
• Creams (eg, CeraVe, Cetaphil, Eucerin, Vanicream, Moisturel, Aveeno) moisturize better than lotions and do not leave as greasy a feel as ointments, which may be a benefit in older patients.
• Ointments (eg, Aquaphor, Vaseline, CeraVe Healing) are very good moisturizers but because of their greasy feel may not be well tolerated by some.

A variety of over-the-counter (eg, CeraVe, Cetaphil Restoraderm) and prescription (eg, Atopiclair, EpiCeram, Hylatopic) barrier repair agents exist that may help reduce the severity of atopic dermatitis and play an adjunctive therapeutic role.

• These agents include products with ceramides, filaggrin degradation products, natural moisturizing factor, avenanthramides, glycyrrhetinic acid, shea nut derivatives, and palmitamide monoethanolamine.
• Although the exact role of these agents is not yet clarified, they may play a role in active disease (usually in conjunction with anti-inflammatory agents such as corticosteroids and calcineurin inhibitors) and as maintenance agents.
• The prescription barrier repair agents typically are more expensive than standard emollients.

Read More about Maintaining the Skin Barrier

Reducing Itch

The chief way to reduce itch is to address xerosis with the daily application of emollients. When the disease is active, however, administer a bedtime dose of a first-generation antihistamine (eg, hydroxyzine 0.5–1 mg/kg, diphenhydramine 1.25 mg/kg) to provide sedation, improve sleep, and reduce scratching.

Daytime doses may occasionally be needed but should be lower (to avoid sedation). 

Wet-wrap therapy may also be useful during severe flares. 

Treating Inflammation

To treat inflammation during a flare of atopic dermatitis, apply a topical corticosteroid twice daily to affected areas until improvement occurs (usually a few days to 2–3 weeks). Ointments are preferred over creams because they tend to be more effective and better tolerated (less burning sensation), although some patients prefer creams because they are less greasy. Choosing a topical corticosteroid depends on the age of the child and the area to be treated.

• Infants (or treatment of the face in a patient of any age): Use a low-potency preparation (eg, hydrocortisone 1% or 2.5%).
• Young children (exclusive of the face): Use a low-potency preparation (eg, hydrocortisone 1% or 2.5%) or, if necessary, a mid-potency preparation (eg, triamcinolone 0.025% or 0.1%, fluocinolone 0.025%).
• Older children and adolescents (exclusive of the face): Use a mid-potency preparation (eg, triamcinolone 0.1%); a high-potency agent (eg, mometasone 0.1%, fluocinonide 0.05%) may be needed for resistant, non-facial areas during a flare.

Once symptoms have improved, the corticosteroid is withdrawn and a moisturizer continued regularly. Super-high-potency topical corticosteroids should not be used for longer than 3 weeks. High- or mid-potency topical corticosteroids can be used for up to 12 weeks. Low-potency preparations have no maximum use recommendations. Although topical corticosteroid use should be avoided in the absence of symptoms, applying a corticosteroid once or twice weekly at locations prone to exacerbations has been shown to reduce relapses and increase the time to the next flare.

Generally, a topical corticosteroid is prescribed for 2 to 3 weeks. The family should be instructed to contact the physician if no improvement occurs in that time. Treatment failure can be due to

• Too low of a potency for the age of the child and skin site
• Incorrect application of treatment by the family
• Bacterial infection

If treatment failure is not caused by those factors, a nonsteroidal topical calcineurin inhibitor or other nonsteroidal topical anti-inflammatory agent can be added to the daily treatment.

For more information on selecting anti-inflammatory agents, see the sections on nonsteroidal topical anti-inflammatories and the information on selecting and prescribing topical corticosteroids.

Rarely, systemic corticosteroids, immunosuppressants, biologicals, small molecule therapies, or phototherapy is necessary for the management of atopic dermatitis. Children with severe atopic dermatitis requiring systemic medication or children with moderate-to-severe disease who are not improving with standard therapy should be referred to a pediatric dermatologist.

Read More about Corticosteroids

Preventing and Managing Skin Infections

To prevent Staphylococcus aureus skin infections, controlling colonization may be useful for those with severe or recalcitrant disease. Consider one or more of the following options:

• Twice weekly 5- to 10-minute baths to which standard (not concentrated) household bleach is added (½ cup in a full tub of water [40 gallons], 1/8 cup in a tub ¼ full of water)
• Use of a sodium hypochlorite body wash (eg, CLn BodyWash) in the bath or shower
• Intranasal mupirocin (twice a day for 5 days)

If there is evidence of secondary bacterial infection (eg, crusting, pustules, oozing [Figure 4.11]), consider administering an oral antistaphylococcal antibiotic (eg, cephalexin or other agent based on local antibiotic resistance patterns) for 7 to 10 days. If no improvement is noted within 48 hours, consider a skin swab for bacterial culture to assess for resistant organisms (eg, methicillin-resistant S aureus) and treat appropriately. At this time, most S aureus isolates from patients with atopic dermatitis in the United States remain methicillin-sensitive.

If infection is limited to very focal areas, a prescription topical antimicrobial agent (eg, mupirocin, retapamulin, ozenoxacin) may be useful.

Daily Measures

• Daily bathing is desirable, if the bath lasts less than 10 minutes and warm (not hot) water is used.
• Apply an emollient as needed to control dry skin. The most effective timing is when applied immediately after bathing (while skin is still moist). Application often is recommended at least once daily, but this will vary with the individual and environmental factors (eg, during warm weather months in humid conditions an emollient may not be needed).
• During colder months when humidity is low one may consider using a vaporizer in the patient’s room at night (taking care to cleanse the device regularly and avoid moisture contact with walls [which could promote mold growth]).
• Use a fragrance-free, non-soap cleanser. Examples include synthetic detergent (ie, syndet) cleansers in bar (eg, Cetaphil Bar, Dove Bar) or liquid (eg, Dove Liquid) forms or lipid-free cleansers (eg, Aquanil, CeraVe, Cetaphil).
• Use an additive-free (fragrance- and dye-free) detergent for laundering clothes (eg, All Free Clear, Ivory Snow, Tide Free and Gentle). If a fabric softener is used, it too should be additive free.
• Wear cotton clothing next to the skin when possible.

Disease Flares and Maintenance Between Flares

When the disease flares:

• Treat inflammation.
• Control pruritus (see the following Wet-wrap Therapy section).
• Control infection.

Wet-wrap Therapy

Wet-wrap therapy may be useful during severe flares of atopic dermatitis. A topical corticosteroid is applied to affected areas and covered with a moistened cotton suit (eg, pajamas), wet gauze strips, or a specially designed, commercially available garment, which is then covered with a dry outer layer (eg, dry pajamas). The wrap may be worn for several hours or up to 24 hours; on removal, emollient is applied. Once the disease flare improves, wet-wrap therapy is discontinued. For more details, including step-by-step instructions on wet wrap therapy, visit the National Eczema Association.

Maintenance Measures

A moisturizer should be used regularly. However, applying a corticosteroid or calcineurin inhibitor once or twice weekly at locations prone to exacerbations has been shown to reduce relapses and increase the time to the next flare.

Phototherapy

Phototherapy may be considered for children who have moderate-to-severe atopic dermatitis and have failed multimodal topical therapy. Phototherapy must be prescribed and conducted by clinicians who are familiar with the various types of phototherapy and equipment. Phototherapy can be used on its own or in combination with emollients and topical steroids.

Dust Mite Avoidance

Avoiding dust mites through frequent vacuuming and encasing pillows and mattresses in allergen-proof products may result in a modest reduction in the severity of atopic dermatitis. Such recommendations are reserved for patients with severe or recalcitrant disease.

Associated Issues

Children with atopic dermatitis may experience other skin conditions, some of which are infectious and others that are cosmetic in nature.

Secondary Infections

Children with atopic dermatitis are prone to certain types of skin infections. The most serious infections (eg, eczema herpeticum) may require hospitalization and treatment with systemic medications.

Any child with atopic dermatitis should not share eating utensils, toothbrushes, drinking glasses, or other personal items with someone who has a cold sore (herpes simplex virus [HSV] 1 infection).

Treatment Regimen by Infection Type

Bacterial Infection

A sudden exacerbation of atopic dermatitis may be caused by a bacterial infection.

The diagnosis is clinical.

• Staphylococcal infections—pustules, oozing and honey-colored crusts, and, less commonly, fever and cellulitis.
• Streptococcal infections—pustules, painful erosions, and fever. The patient may have facial or periorbital involvement or invasive infections.

If there is evidence of secondary bacterial infection (eg, crusting, pustules, oozing [Figure 4.11]), consider administering an oral antistaphylococcal antibiotic (eg, cephalexin or other agent based on local antibiotic resistance patterns) for 7 to 10 days. If no improvement is noted within 48 hours, consider a skin swab for bacterial culture to assess for resistant organisms (eg, methicillin-resistant Staphylococcus aureus [MRSA]) and treat appropriately. At this time, most S aureus isolates from patients with atopic dermatitis in the United States remain methicillin-sensitive.

If infection is limited to very focal areas, a prescription topical antimicrobial agent (eg, mupirocin, retapamulin, ozenoxacin) may be useful.

The choice of topical, oral, or intravenous antibiotic therapy (against S aureus and streptococci) depends on the extent and severity of the infection.

• Topical mupirocin can be used for limited skin lesions.
• Cephalexin (7- to 10-day course) is a common first-choice when MRSA is not suspected.
• Simultaneously treat for repair of skin barrier.

Eczema Herpeticum

Eczema herpeticum is a disseminated HSV infection that occurs in individuals who have atopic dermatitis or other chronic skin diseases. It occurs primarily in children younger than 3 years. It likely is the result of a disrupted skin barrier that allows viral invasion.

• Clinical
  • Patients develop fever, malaise, and a widespread eruption composed of vesicles, punched-out erosions, and ulcers.
  • Complications include secondary bacterial infection (most often with S aureus), keratoconjunctivitis (for those with lesions involving the eye), and, rarely, viral dissemination with multiple organ involvement, meningitis, or encephalitis.
• Diagnosis: usually made clinically with confirmation by polymerase chain reaction testing or viral culture of vesicular fluid
• Treatment
  • Acyclovir administered orally (most patients) or intravenously (in infants and those with systemic symptoms, toxicity, and extensive disease) for 7 to 10 days.
  • Because recurrences are common, daily antiviral prophylaxis may be warranted.
  • If secondary bacterial infection is suspected, performing a skin culture and treating with an antibiotic active against S aureus is indicated. For those with widespread involvement, the parenteral route often is chosen.
  • Many experts avoid the use of topical corticosteroids (eg, triamcinolone) during the acute phase of eczema herpeticum, although evidence supporting this recommendation is limited. Topical calcineurin inhibitors (eg, tacrolimus, pimecrolimus) are contraindicated.

Noninfectious Conditions

Keratosis Pilaris and Ichthyosis Vulgaris

• Advise patients and families there is no cure and the course may be variable.
• Use a standard emollient or one containing a keratolytic agent (eg, AmLactin, Lac-Hydrin, Carmol, CeraVe SA, Eucerin Professional Repair) twice daily as needed; may soften papules and make them less noticeable.
• Good dry skin care is vital.

Pityriasis Alba 

• Apply an appropriate topical corticosteroid twice daily (eg, for the face, hydrocortisone 1%) for 2 to 3 weeks to treat any existing inflammation (topical calcineurin inhibitors or phosphodiesterase inhibitor may also be useful in this regard [off label]).
• Sun protection may be used to reduce the contrast between unaffected skin (which will become darker with sun exposure) and affected skin (in which there is temporary melanocyte dysfunction).
• The patient and family should be counseled that several months might be required for typical pigmentation to return.

Medications

Ensure that eczema is not undertreated. Families are often reluctant to use corticosteroids (sometimes called “corticophobia”). Some doctors can be reluctant to prescribe them.

Topical corticosteroids are the first-choice therapy for eczema flares and their benefits greatly exceed uncommon adverse effects.

When used as directed the safety profile of new topical corticosteroids is good. Insufficient or inadequate applications of topical corticosteroids limit the ability to control dermatitis, leading to multiple issues including poor quality of life and increases in flares. Especially in severe forms of atopic dermatitis, it is important to implement a multidisciplinary approach, in which education has an important role.

Nonsteroid Topical Anti-inflammatories

• Noncorticosteroid topical calcineurin inhibitors (TCIs) (eg, tacrolimus [Protopic], pimecrolimus [Elidel]):
  
  • • TCIs are used as second-line agents in patients older than 2 years for whom topical corticosteroids fail or when avoidance of more potent topical corticosteroids is desired (eg, treatment of the face).
      • They reduce inflammation by decreasing T-cell activation and pro-inflammatory cytokines.
      • TCIs are beneficial because they avoid potential local or systemic corticosteroid adverse effects.
      • Tacrolimus is available in 2 strengths: 0.03% (approved for 2–15 years) and 0.1% (approved for 16+ years).
      • The US Food and Drug Administration advises using these agents only for active areas of dermatitis and discourages chronic long-term application. A black box warning issued in 2006 concerns the hypothetical risk that TCIs may increase long-term cancer risk. However, studies have not shown increased risks with their use.
        
        • Association between topical calcineurin inhibitor use and keratinocyte carcinoma risk among adults with atopic dermatitis
        • No evidence of increased cancer incidence in children using topical tacrolimus for atopic dermatitis
      • Use as monotherapy twice daily or in conjunction with topical corticosteroids (eg, a topical corticosteroid is applied morning and afternoon and the topical calcineurin inhibitor at bedtime).
      • Once symptoms have improved, application of a topical calcineurin inhibitor 2 to 3 times weekly at locations prone to exacerbations has been shown to reduce relapses.
• Non-corticosteroid Phosphodiesterase Inhibitor (eg, Crisaborole [Eucrisa]):
  • This nonsteroidal anti-inflammatory agent is not associated with local or systemic corticosteroid adverse effects. It is approved for children 2 years and older and is applied twice daily to affected areas. Some burning may be reported with application.
  • Other phosphodiesterase inhibitors including roflumilast are in phase III trials.
• Janus kinase (Jak) pathway inhibitors
  • Ruxolitinib (Opzelura) 1.5% topical cream was approved in September 2021 for use in children 12 years and older. It is intended for short-term use (up to 8 weeks) for mild-to-moderate atopic dermatitis, for not more than 20% of body surface area, and not to exceed 60 g per week. It should not be applied to patients who are immunocompromised, have a skin infection, or are taking an immunosuppressant or biological. Ruxolitinib tends to work quickly, often reducing itch by the second day of use.
• Systemic Anti-inflammatory Medications
  Systemic therapies are considered for those with moderate-to-severe disease that is unresponsive to standard treatments. They are best administered by a pediatric dermatologist or pediatric allergy-immunology specialist who is experienced using these medications.
  
  • o Dupilumab (Dupixent) is an antibody to the IL-4 alpha receptor and decreases pro-inflammatory cytokines. It is approved for use in infants and children 6 months and older. It effectively decreases symptoms after 1 to 2 months of use and shows increases in effectiveness as duration of treatment increases. It has an excellent safety profile, although long-term–use (> 3 years) safety studies are limited. Nasopharyngitis is the most common side effect. Dupilumab is administered as a subcutaneous injection and may be combined with topical corticosteroid, TCI, and phototherapy. (Note that immunization with live or attenuated virus is contraindicated in children just before or during treatment with dupilumab.) Dosing and frequency are weight based in the pediatric population.
  • Upadacitinib: This Jak inhibitor is administered orally (as a tablet) and is approved for children and adolescents 12 years and older who weigh more than 88 pounds (40 kg). A black box warning issued in 2021 addresses the risks of serious heart-related events, cancer, blood clots, and death.
  • Methotrexate: A low-cost, off-label option for long-term symptom control of severe atopic dermatitis, methotrexate is well-tolerated in children. Gastrointestinal distress is the most common side effect; folic acid supplementation may be considered to mitigate the antagonistic effect on folic acid. Subcutaneous delivery is better tolerated than oral delivery. Methotrexate is usually given only once per week and requires blood work monitoring.
  • Cyclosporine: Off-label option for short-term use in those with severe atopic dermatitis. Cyclosporine is usually given orally twice daily and requires blood work monitoring and following for renal impairment. Cyclosporine should not be offered to those children who receive phototherapy. The therapeutic index is narrow and monitoring for renal impairment is necessary.

Discussing With Parents and Families

Clinical practice guidelines recommend educational programs (“eczema schools”) as an adjunct to therapy for atopic dermatitis.

The treatment regimen for atopic dermatitis is complex and multifactorial; therefore, support for the patient and caregivers is crucial in increasing treatment compliance. Research into certain formal programs has shown improvements in ability to cope, itching behavior, and disease severity. Options include nurse-led sessions and video education.

Patients and families may wish to explore alternative treatments. It may be helpful to solicit information about alternate treatment plans and to share the results of scientific studies of alternative treatments.

When to Refer

Between 80% and 90% of infants experience a spontaneous resolution or improvement in symptoms by adolescence. Until this time the disease course is chronic and relapsing. Consider a referral to a pediatric dermatologist when patients do not respond to standard treatments.

Other reasons for referral

• Poorly controlled or generalized atopic dermatitis in children who are candidates for systemic immunosuppressive therapy (methotrexate, cyclosporine [off-label]), biological therapy (eg, dupilumab), small molecule therapy (eg, ruxolitinib, upadacitinib), or phototherapy
• Recurrent infections (viral or bacterial)
• Suspected allergic contact dermatitis
• Presence of atypical features or physical examination findings
  
  

The development of this information was made possible through support from Sanofi and Regeneron.