The American Academy of Dermatology (AAD) has, for the first time, issued guidelines of care for the medical management of pediatric eczema. Commonly known as pediatric atopic dermatitis (AD), this condition generally starts before the age of 5 and affects up to 25% of children worldwide.
The AAD’s Atopic Dermatitis Guideline Workgroup, comprising 11 dermatologists and one pediatric allergist, published the guidelines in two parts in the Journal of the American Academy of Dermatology. The publication includes 27 evidence-based recommendations for medical management, 14 evidence-based recommendations for the primary prevention of pediatric AD, and an additional 29 statements addressing associations between pediatric AD and comorbid conditions.
According to Murad Alam, MD, MBA, MSCI, FAAD, president of the AAD, “Pediatric eczema is not the same as adult eczema, as it manifests differently and carries a significant burden for both children and their caregivers.” He emphasized the need for “dedicated, age-appropriate guidance” in treating pediatric AD.
“These new guidelines from the American Academy of Dermatology are an important step toward ensuring our youngest patients receive the evidence-based care they deserve,” he added.
Recommended Treatment Options
The workgroup, co-chaired by Dawn Marie R. Davis, MD, and the late Robert Sidbury, MD, MPH, outlined a range of treatment recommendations. They also noted that a simple one-step daily skin care regimen may be just as effective as a two-step approach, helping streamline the process for patients and caregivers.
“The use of topical steroids for eczema patches alone was found to be just as efficacious and no better than using topical steroids with a moisturizer,” said Dr. Davis. “You do not necessarily have to use a topical steroid and a moisturizer together. The topical steroid can be used in isolation.”
The workgroup strongly recommended:
- Moisturizers to soothe dry, itchy skin
- Topical calcineurin inhibitors (pimecrolimus 1% cream and tacrolimus 0.03% or 0.1% ointment) to be used intermittently as maintenance therapy
- Topical corticosteroids of low-to-medium potency as maintenance therapy up to three times per week
- Phosphodiesterase-4 inhibitors, including crisaborole (for patients aged 3 months and older) and roflumilast cream (for patients aged 2 years and older with mild-to-moderate disease)
- Topical JAK inhibitor ruxolitinib cream for patients aged 2 years and older with mild-to-moderate disease
- Topical aryl hydrocarbon receptor agonist tapinarof cream for patients aged 2 years and older
- Biologics, including dupilumab (for patients aged 6 months and older), and tralokinumab and lebrikizumab (for patients aged 12 years and older with moderate-to-severe disease)
- JAK inhibitors, including upadacitinib, abrocitinib, and baricitinib for patients aged 12 years and older with moderate-to-severe disease
The workgroup issued conditional recommendations for:
- Bathing strategies, including diluted bleach baths under medical guidance to treat flares and maintain clearance
- Wet dressings with topical corticosteroids during AD flares
- Phototherapy
What Not to Do
The workgroup strongly recommended against the use of systemic corticosteroids for patients under 18, except for short-term management of severe flares.
“Systemic corticosteroids suppress the immune system and oftentimes will clear dermatitis or greatly improve dermatitis,” Dr. Davis explained. “When they withdraw from the steroids, patients with AD tend to have rebound flares, such that they have worse dermatitis than when they started the treatment. Exposure to systemic corticosteroids can cause side effects that impact quality of life; therefore, the benefits do not outweigh the risks.”
The workgroup also issued a conditional recommendation against psoralen ultraviolet-A phototherapy (photochemotherapy), which increases the long-term risk for developing skin cancer and photoaging damage, as well as topical antimicrobials for children with AD when there is no sign of infection.
Additionally, the guidelines found no evidence to support several commonly used prevention strategies, including special diets, specific infant formulas, supplements, or changes in bathing frequency.
“There is no evidence for using water softeners, dust mite avoidance techniques, special types of formula, early food introduction, probiotic use, or vitamin D supplementation to prevent the development of AD,” Dr. Davis noted. She added that there is no supporting evidence for systemic antibiotics or oral antihistamines, despite their common use.
Increasing Awareness on Pediatric Eczema
What can assist in prevention and management is awareness of key comorbidities associated with pediatric AD. The workgroup found that AD is highly associated with eosinophilic esophagitis and moderately associated with food allergies, asthma, hives, anxiety, obesity and metabolic syndrome.
“While the medical community was aware of the association between AD and eosinophilic esophagitis, food allergies, asthma and urticaria, I don’t think that we were very well aware of the association between AD and anxiety, obesity and metabolic syndrome,” Dr. Davis said. “Being aware of this empowers and educates patients so they can seek help and intervention from relevant specialists and be proactive rather than reactive, to have the best quality of life and health possible.”
While Dr. Davis notes that several research gaps remain, including identifying optimal moisturizer ingredients and conducting head-to-head trials, she emphasized the significance of these guidelines.
“This is a step forward for children in the community,” she said. “I’m looking forward to our colleagues, patients and their families referencing and learning from these guidelines.”
