Atopic%20dermatitis%20(pediatric) Treatment

Corticosteroids (Topical)

• Used as 1st-line treatment for mild to severe atopic dermatitis
• Moderately potent and potent corticosteroids should be used for the treatment of clinical exacerbation over short periods of time
• Mildly potent corticosteroids are recommended for maintenance therapy
• Anti-inflammatory and antipruritic activity through several mechanisms
  • Alteration in leukocyte number and activity
  • Suppression of mediator release (histamine, prostaglandins)
  • Enhanced response to agents that increase cyclic adenosine monophosphate (prostaglandin E₂ and histamine via the histamine-2 receptor)
• Rapid symptomatic relief of acute flare-ups
• Continuous use can lead to adverse effects, thus recommended restrictions regarding intensity and duration of use on delicate skin areas (eg face, neck and skin folds) should be followed
• May occasionally cause hypersensitivity reactions in non-resolving or worsening atopic dermatitis despite good compliance with application 
• Topical corticosteroids are available in different potencies from mild to very potent
  • Potency is also affected by the vehicle the product is formulated in (eg cream, ointment)
• Choice of product will depend on severity of flare-up, distribution of lesions and other factors (eg humidity)
• Least potent but effective product should be used
• Rebound flaring can occur if higher potency preparations are discontinued abruptly
  •  A gradual decrease in potency should follow use of higher potency preparations
•  Therapy-resistant lesions may require potent topical corticosteroid used under occlusion for a short period of time and under close supervision

Calcineurin Inhibitors (Topical)

• Inhibit inflammatory cytokine transcription in activated T cells and other inflammatory cells through inhibition of calcineurin
• Second-line therapy for patients with chronic atopic dermatitis unresponsive to, intolerant of, or with contraindications to other topical therapies
  • Helps reduce subsequent flare-ups or relapses with intermittent use
• Equated to medium potency strength of topical corticosteroids 
• May be used on all body locations for extended periods of time, especially the face, hands and feet
• All preparations are of a standard potency
• Common side effects: Transient burning, erythema and pruritus
• Avoid the use of these agents in children younger than 2 years of age
• Use only for short periods of time using minimum amount necessary to control symptoms
• Avoid continuous use and avoid use in patients with compromised immune systems

Pimecrolimus

• Safety and efficacy has been shown in children >2 years of age with mild-moderate atopic dermatitis
  • Pruritus relief has been seen as early as day 3 of use
  • Prevents flare-ups and results in significant steroid-sparing effect when used for up to 12 months
• When used in early stages of disease, it has shown to be therapeutically advantageous over typical moisturizers plus topical corticosteroids in long-term use

Tacrolimus

• Indicated for moderate-severe atopic dermatitis
  • May be used for up to 1 year without loss of effectiveness, increase in infection risk or other non-application-site adverse effects
  • Well-tolerated with transient skin burning/irritation
• Studies have confirmed the efficacy of Tacrolimus 0.03% compared to low potency topical corticosteroids in children

Biological Agents
Dupilumab

• The first human monoclonal antibody approved for 1st-line treatment of moderate to severe atopic dermatitis for children ≥12 years old unresponsive to topical treatments and cannot tolerate systemic treatments
• Significant improvements in disease activity, symptoms, and quality of life were seen in patients given Dupilumab involved in several clinical studies

Other Biological Agents

• Other biologicals undergoing clinical trials or are currently being used as off-label therapy for atopic dermatitis include Baricitinib, Fezakinumab, Lebrikizumab, Mepolizumab, Nemolizumab, Omalizumab, Rituximab, Tezepelumab, Tofacitinib, Upadacitinib, and Ustekinumab

Skin Infections¹

• Clinical infections at treatment sites should be cleared before starting anti-inflammatory agents
• May need to treat reservoirs of the infection to prevent recurrence (eg nose, groin)

Bacterial Infections

• S aureus is commonly cultured from eczematous skin and is often the cause of localized infections
• Topical therapy
  • May be used to treat mild and localized secondary infection
  • Fusidic acid, Mupirocin, and Retapamulin are treatment options
  • Neomycin may cause allergic contact dermatitis
  • Retapamulin is recommended for children ≥9 months
  • Prolonged use should be avoided to decrease risk of bacterial resistance
• Oral therapy
  •  Usually necessary to treat widespread infected lesions
  •  Anti-staphylococcal penicillins, macrolides, 1st and 2nd generation cephalosporins and Clindamycin are treatment options

Viral Infections

• Patients may develop secondary herpes infections inclusive of eczema herpeticum (Kaposi’s varicelliform eruption) and may require systemic Acyclovir treatment in a hospital setting
• Prophylactic oral antiviral agents may be used to suppress recurrent cutaneous herpetic infections

Fungal Infections

• Role of fungi in atopic dermatitis is questionable
• Superficial dermatophytosis and Pityrosporum ovale may be treated with systemic or topical antifungals

Antihistamines¹

• Oral sedating antihistamines may be useful if the patient has comorbidities (allergic rhinitis, urticaria or dermatographism) and sleep disturbance
  • They are best used at bedtime since pruritus is typically worse at night
• Studies of oral non-sedating antihistamines have shown variable results in controlling pruritus, however they may be useful in a small group of patients with associated urticaria
•  Topical antihistamines are usually not helpful in relieving pruritus and may cause allergic contact dermatitis

Systemic Corticosteroids¹

• Should only be considered in treatment-resistant atopic dermatitis
• Improves lesions but rebound flare-up usually occurs upon discontinuation
• Use short-term and decrease chance of rebound effect by tapering oral form slowly while increasing topical corticosteroid treatment and continuously hydrating the skin

Systemic Immunosuppressants (Oral)¹ 

Ciclosporin

• Effective for short-term use in severe refractory disease
  • Condition tends to return after discontinuation of therapy but not always at the original severity level
•  Long-term use is not justified because of risks of hypertension and renal dysfunction

Azathioprine

• Used for severe/refractory disease
• Thiopurine methyltransferase (TMPT) levels should be taken pretreatment and while on treatment to determine dose and test for myelosuppression to decrease risk of myelotoxicity
• Monitor hematologic and liver function parameters
• Safer than Ciclosporin and has been used long-term
  • Most patients respond to low doses
• Adverse reactions: Nausea, fatigue, myalgia, liver dysfunction and bone marrow depression in patients deficient in thiopurine methyltransferase

¹Various antibiotics, antifungals and antivirals are available. Please see prescribing information for specific formulations in the latest MIMS.

Avoidance of Trigger Factors

All Irritants

• Lipid solvents (soaps, detergents)
  • New clothes should be laundered before wearing to decrease levels of formaldehyde and other chemicals added
  • When washing, use liquid instead of powder detergent, and do another rinse cycle to remove detergent completely from clothes
• Disinfectants (swimming pool chlorine)
• Occupational irritants
• Household fluids (meats, juices from fresh fruits)

Contact and Aeroallergens

• Furry animals (cats, dogs)
• Molds
• Human dander (dandruff) resulting in overgrowth of yeast
• Dust mites
  • Avoidance include use of dust mite-proof encasings on pillows and mattresses, washing bedding in hot water weekly remove bedroom carpeting and curtains, decrease indoor humidity level by air conditioning, avoid upholstered sofa

Others

• Foods
  • Flaring/occurrence of atopic dermatitis with a specific food may warrant elimination diet in patients with moderate-severe atopic dermatitis
  • Skin prick tests (SPT) and measurement of specific immunoglobulin E (IgE) are used to determine sensitization to a particular food
  • Limited food allergy testing may be considered in children <5 years with moderate-severe atopic dermatitis and disease unresponsive to previous therapies and/or with history or allergic reaction to a specific food
  • Negative results are useful for ruling out suspected allergens
• Climate
  •  Consider temperature and humidity control to avoid increased pruritus due to heat and perspiration
  •  Prolonged sun exposure may increase evaporative losses due to sweating
•  Hormones (menstrual cycle)
•  Psychological factors
  •  Emotional factors (eg anxiety and anger) cause disease exacerbation, induce immune activation and increase pruritus and scratching
  •  Psychological evaluation and counseling should be considered in patients who have difficulty with emotional triggers or who have psychological problems

Skin Care

• Hydration of skin with emollients is essential in atopic dermatitis treatment

Bathing¹

• Soap substitutes with minimal defatting activity and a neutral pH are preferred
• Soaking bath or shower daily for 10-15 minutes using warm water and “soak-and-seal” approach not to exceed 2 baths in 1 day
  • “Soak-and-seal” is the immediate application of prescribed topicals and emollients after bathing
  • May also consider using bath oils within the last 2 minutes of bathing
• Topical medications are best applied after bathing because of greater penetration of hydrated skin
• Bleach baths with intranasal Mupirocin may be used for moderate-severe disease with frequent bacterial infections
• Salt baths may be used in patients with heavily impetiginized or ichthyotic skin
• Oatmeal products added to bath may be soothing but do not increase water absorption by the skin

Moisturizers¹

• Water-in-oil emollients are preferred
• Patient preference and treatment area will determine formula used in emollients (eg palmitoylethanolamide (PEA), liquid paraffin, mineral oils, glycerin, etc)
• Effects: Moisturizers help re-establish and preserve the stratum corneum
  • Can decrease the need for topical corticosteroids
• Should be applied all over at least twice daily or as often as possible, regardless of the presence of active dermatitis
• Avoid products with preservatives or fragrances
• If product stings, it should not be used

Wet Dressings

• May be used on weeping lesions or severely affected areas
  • Discomfort, folliculitis and impetigo reported as common adverse effects
  • Can help reduce water loss and disease severity in patients with moderate-severe atopic dermatitis
• Combined with topical corticosteroids can be effective in treating refractory cases
  •  Temporary increased systemic absorption of corticosteroids reported

Phototherapy

• Broad-band ultraviolet B (UVB) and ultraviolet A (UVA), narrow-band UVB and UVA-1 or combined UVA and UVB can be useful in atopic dermatitis
• Narrowband UVB is the initial phototherapy of choice due to its safety profile and availability
• Phototherapy should be avoided in infants and young children
• Photochemotherapy with Psoralens and UVA should be restricted to patients with widespread severe atopic dermatitis
• UV therapy should be reserved for pediatric patients older than 6 years of age who present with severe refractory atopic dermatitis
• A yearly skin exam is recommended if with continued phototherapy
• Relapse following cessation of therapy frequently occurs
• Adverse reactions:
  • Short-term: Erythema, skin pain, pigmentation, itching
  • Long-term: Premature skin aging and potential cutaneous malignant diseases