Clinical Management of Atopic Dermatitis Across Childhood
Clinical Summary
Pediatric Atopic Dermatitis: Flare Control, Maintenance, and Systemic Therapy Selection
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Flare management (pediatric AD): Use medium–potent topical corticosteroids aggressively for short courses (weeks); low concern for long-term safety in this setting. Inadequate control or need for continuous medium–potent topical use → escalate to systemic therapy.
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Maintenance strategy: Individualize; options include proactive topical therapy 2–3×/week (steroids, calcineurin inhibitors, or nonsteroidals) or intermittent use after flare control. Avoid daily long-term topical steroids.
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Systemic options (pediatrics): Dupilumab is the primary option for <12 years (effective, long-term safety). Future options include IL-13, IL-31R inhibitors, and JAK inhibitors (currently ≥12 years; baricitinib available ≥2 years in Europe); address adherence barriers (e.g., injection techniques).
Reviewed by Riya Gandhi, MA, Associate Editor of Immunology Group
Dr Amy Paller discusses how advances in understanding type 2 inflammation are transforming pediatric atopic dermatitis care. Learn when to initiate systemic therapy, how to manage flares safely, and practical strategies for long-term disease control, including the role of dupilumab and emerging targeted treatments.
Transcript
Hi, I'm Dr Amy Paller. I'm Professor and Chair of Dermatology at Northwestern University Feinberg School of Medicine in Chicago. And I'm an attending and pediatric dermatologist at Lurie Children's Hospital of Chicago.
When managing flares in children, how do you balance the need for rapid disease control with long-term safety considerations, particularly in younger patients?
Dr Paller: When we're managing flares, I don't worry about long-term safety. You can give a potent steroid to a child for a few weeks at a time, and it will have no short-term or long-term safety concerns. So I am very aggressive with managing flares. And I think one of the problems in treating children with atopic dermatitis is the failure to treat more aggressively and get the disease under control. In fact, I think that the more difficult management decision is in how to maintain in a manner that is safe long-term. So flares, usually one can get under control with a good medium to potent topical corticosteroid; those in whom one cannot do that effectively, or those in whom one requires continued daily use of a medium strength to potent topical corticosteroids, should be candidates for advancing to systemic therapy.
As I mentioned, it is the maintenance that is more challenging, and that really has to be personalized. Is this a child with more limited areas of involvement who can use proactive management in which we aggressively get the disease under control and then dial down to continue either a topical corticosteroid or a topical calcineurin inhibitor, or perhaps even one of the newer non-steroidal agents, applying it 2 - 3 times a week to those areas that would recurrently flare if one didn't continue to have some anti-inflammatory topical applied a few times a week. Some kids do well with that. Some do so well after you've originally hit hard with more aggressive management or a few weeks initially that they only need intermittent topical corticosteroids after that. And in my book, I don't care then if you're using something relatively strong, medium-strength, or potent, if it's just intermittent for a few days of time back to an ammonium.
And then there are some who will do okay with hitting hard when you have a flare and then just using some low-strength topical alternatives, whether that be a topical corticosteroid or a nonsteroidal alternative, more as a maintenance. As long as one is not using long-term topical steroids on a daily basis to keep somebody under control, you're probably going to have one of these safer alternatives for maintenance, and that's fine. But again, if not, one should be thinking about advancing to a nonsteroidal, ideally non-immunosuppressant agent that is systemic for long-term control.
How do you decide when topical therapy is no longer sufficient and it’s time to consider systemic treatment in pediatric patients?
Dr Paller: If topical therapy with an anti-inflammatory agent, and specifically with a medium-strength to potent topical corticosteroid, is required to have some degree of comfort for that particular child is required to keep the disease under control, then I think it's time to consider systemic treatment. Certainly, in anyone in whom topical therapy of at least medium-strength or potent topical corticosteroid or other nonsteroidal is insufficient, then it's also time to consider systemic treatment.
What practical advice do you give dermatologists about selecting among available systemic options for children with moderate-to-severe atopic dermatitis?
Dr Paller: We're fortunate that we have a growing list of options for our pediatric patients that are systemic. Unfortunately, for those who are under 12 years of age, at this time, the only option is dupilumab. That said, the use of dupilumab has very much revolutionized our ability to manage with quick anti-inflammatory activity and control, and continuing on a long-term basis, at least for years of experience now, showing continued safety. I'm looking forward to having other alternatives, for example, your IL-13 inhibitors, your anti-IL-31 receptor inhibitor for itch specifically, and then your JAK inhibitors that are now only available for 12 years and above, that is, the adolescence, to be able to move that into the pediatric realm. So we have choices if the dupilumab is either not tolerated or is not working effectively enough to move to an alternative agent, or even start with one of those if there is a rationale for that.
Right now, for younger children, all we have is a biologic with other biologics coming, and maybe in the future, JAK inhibitors. I should mention that baricitinib is available in Europe down to 2 years of age, but we have no JAK inhibitor right now below 12 years of age. The problem that we have with using a biologic, whether that's dupilumab or others in the future in younger children is the pain associated with injection and the tension that that can cause when every 4 weeks or every 2 weeks, a shot is required for the child who just doesn't get used to it and screams all the time, really creating a problem for many parents who can't deal with that possibility.
So the advice that I have is that we've published and we certainly give a lot of practical suggestions on how to give injections in children, including having a child sitting on the lap of a parent who holds the child in a bear hug, never, of course, asking a child to lie down for a shot, which will provoke tremendous anxiety. Also, very important in this situation, to establish distraction techniques, anything from visual distraction to auditory distraction, I've even heard of someone sucking on a sour lemon candy as another means of distraction, but having these means, including virtual reality, to relax a child, to be able to do that shot, which only takes a few minutes. We can also use tactile stimulation, something very cold nearby to the area of the shot or something that is stimulating in other ways, whether it's just pressure or vibration, as examples. There are several other techniques that one can think about to help to reduce that burden, but nevertheless, the most important practical advice is to figure out a routine that allows that injection to be given in the least traumatic way possible for the child.
