American Academy of Dermatology Issues First Pediatric Atopic Dermatitis Guidelines

For the first time in its history, the American Academy of Dermatology (AAD) has published guidelines of care for both the prevention and management of atopic dermatitis (commonly known as eczema) in pediatric patients.

While pediatric and adult eczema share similarities, these guidelines recognize the unique safety, dosing, and patient-caregiver-clinician interactions of individuals under the age of 18. The most common pediatric skin disease, eczema, affects up to 25% of children worldwide. The condition is a long-lasting inflammatory skin disease marked by itchy skin, dry patches, rashes and rough bumps.

“Eczema is extremely common in children, though it doesn’t always look or behave the same way it does in adults,” said AAD President and board-certified dermatologist Murad Alam, MD, FAAD. “Because eczema can decrease the quality of life of children and their families, we need dedicated guidelines just for children to ensure their best care.”

New Guidelines

The new guidelines, published in the Journal of the American Academy of Dermatology (JAAD), will guide dermatologists in deciding the best possible prevention and treatment options for pediatric patients. The guidelines were developed by a working group of 14 experts, including 11 board-certified dermatologists and one pediatric allergist.

Because eczema is so common and can significantly affect a child’s health, there is strong interest in identifying ways to help prevent it. However, current research shows that supplemental therapies like special diets or skipping baths aren’t proven to prevent eczema. Moisturizers were the only treatment to receive a conditional recommendation for use to reduce the occurrence of eczema in children aged 6 months to 3 years. Conditional recommendations reflect an intervention whose benefits are closely balanced with risks and burdens. These recommendations apply to most patients, but the most appropriate action may differ depending on the patient and presentation.

The guidelines find insufficient evidence or no benefit to dietary or environmental interventions, including early food introduction, human milk consumption, probiotic or vitamin D supplementation, water softening, and dust mite avoidance.

“These guidelines were developed to educate and empower patients, caregivers, and the medical community so children with eczema receive the best care possible. Early, proactive intervention allows improvement in symptoms and quality of life for patients and their families,” said board-certified dermatologist Dawn Davis, MD, FAAD, co-chair of the AAD’s Atopic Dermatitis Guideline Workgroup. “Since 2014, the landscape for eczema care has been transformed by the approval of new therapies for adults. Our goal was to review how these advancements relate to the pediatric population so children also receive optimal, individualized care.”

Treatment Options

There are more treatments for eczema than before, says the AAD, though standard treatments like regular moisturizing remain effective in managing eczema in children.

The guidelines provide 26 evidence-based recommendations for topical therapies (prescription and non-prescription), phototherapy, and systemic therapies based on the treatment’s reduction of eczema symptoms and itch severity.

Strong recommendations reflect treatments in which benefits outweigh the risks and burdens. These recommendations apply to most children with eczema in most circumstances.

Recommendations

Strong recommendations were made for the use of the following:

Moisturizers to reduce the severity of patients’ dry, itchy skin;

Topical calcineurin inhibitors (pimecrolimus 1% cream and tacrolimus 0.03% or 0.1% ointment) to manage patients’ flares when their dry, itchy skin worsens and as intermittent maintenance therapy.

Topical corticosteroids (steroid creams), considered a first-line treatment in most cases due to affordability and accessibility, to manage patients’ flares and as maintenance therapy;

Phosphodiesterate-4 inhibitors (crisaborole ointment and roflumilast cream) to reduce patients’ itchiness and decrease the frequency of flares. When used proactively, roflumilast can keep skin clearer more consistently;

Topical JAK inhibitors (ruxolitinib cream) to decrease the severity of the dry, itchy skin in patients with mild to moderate eczema;

Topical aryl hydrocarbon receptor (AhR) agonists (tapinarof cream) to reduce inflammation, improve skin barrier function, and decrease the severity of dry, itchy skin in patients with mild, moderate and severe eczema;

Monoclonal antibodies (dupilumab, tralokinumab, and lebrikizumab) to decrease the severity of eczema symptoms, reduce flares and improve itching in patients with moderate to severe eczema;

JAK inhibitors (upadacitinib, abrocitinib, and baricitnib) to decrease the severity of eczema symptoms and improve itching in patients with moderate to severe eczema.

Conditional Recommendations

Conditional recommendations were made for the use of treatments inclusive of the following:

Bathing for treatment and maintenance for pediatric patients, followed by a moisturizer as standard care;

Wet wrap therapy, under the guidance of a healthcare professional skilled in eczema management, are typically encouraged for patients during eczema flares; and

Phototherapy (light therapy) at a dermatologist’s office can be used to treat patients with severe cases of eczema involving many body sites.

Strong recommendations were made against systemic corticosteroids, which officials said should be reserved exclusively for patients with sudden, severe flares and as short-term bridge therapy. Conditional recommendations were made against the use of topical antimicrobials and PUVA phototherapy for children with eczema.

Read about a recent study conducted by the L’Oréal Research & Innovation on hope for treatment options, here.