Conflicts of interest:
None declared
The diagnostic work-up of atopic dermatitis (AD, atopic eczema) was discussed in part I1. This part of the medical algorithm focuses on the therapy of AD in early childhood and is based on international guidelines2-4.
The management of AD is mainly based on the severity. Assessment of disease severity has already been discussed in part I. Basic therapy of the disturbed skin barrier is always necessary, i.e. also for children that do not suffer from active lesions. Normally, topical treatment is the first choice. If topical anti-inflammatory treatment fails, and patient adherence and compliance have been addressed, or in case of severe and very severe disease, phototherapy or systemic therapy are indicated (step-up approach, see Table 12,3).
Basic therapy consists of emollients to moisturize the skin and improve barrier function, advice on daily skin care and hygiene/bathing, and avoidance of trigger factors (including allergens). Adherence to (basic) therapy and correct drug use have to be addressed. Counseling needs to be focused on allergen avoidance (if confirmed by allergy testing and deemed relevant [e.g. food]), possible cross reactions, and alimentary substitutes. In addition, also individual non-allergic trigger factors should be identified and patients and their parents need to be counseled in order to know how to cope with these factors (which are not always avoidable). Therapeutic patient education (e.g. ‘eczema school’) and written instruction plans are of great importance because many patients with AD can achieve disease control with optimized skin care and mild topical treatments5.
Mild AD can usually be controlled with reactive therapy in addition to basic therapy. Moderate-severe AD often requires subsequent proactive therapy with topical corticosteroids (TCS) (with or without wet wraps) or topical calcineurin inhibitors (TCI). The choice for the best approach with regard to corticosteroid potency and class depends on age and body site (e.g. lower potency for the face versus higher potency for the trunk). The choice for vehicles (oil-in-water versus water-in-oil) for topical corticosteroids depends on lesion characteristics (moist versus dry), and patient preference/adherence. The fingertip unit (FTU) method should be used for optimal dosing: one fingertip of cream for an area of two adult palms. There is conflicting evidence on once versus twice-daily application6. TCI also can be used off-label in children <2 years3. The choice of topical anti-inflammatory drug depends on local cofactors (e.g. in moderate-severe AD it is recommended to start with TCS instead of TCI because the latter can evoke stinging in inflamed skin). Topical phosphodiesterase inhibitors are a treatment alternative.
For all patients, depending on the individual situation and disease course and severity, other non-pharmacological options can be used. Silver coated textiles can be used to decrease Staphylococcus aureus colonization on the skin (conflicting evidence). Psychological counseling should be considered with regard to individual family psychodynamics. Climate therapy at high altitude has shown beneficial effects on atopic dermatitis, probably due to UV exposure, avoidance of allergen exposure, and decreased stress7.
For severe AD, or for cases that do not respond well to topical therapy, wet wrap therapy can be initiated in an inpatient or outpatient setting8. Ultraviolet (UV) therapy is used reluctantly in early childhood due to the cumulative UV dosage, time necessary, and anxiety in the UV cabin). If used, narrowband ultraviolet B (311 nm) or ultraviolet A1 is preferred. All other systemic medication is off-label in early childhood. However, there is ample clinical experience with use of cyclosporine A (fast-acting and approved in Europe from age 16 years) and methotrexate, which is a safe alternative but clinical improvement takes longer. Cyclosporine A is known for nephrotoxicity and risk for hypertension, so blood pressure and renal function have to be monitored. Methotrexate is known for hepatotoxicity. Other options are azathioprine (side effects: infection, nausea, cancer) and mycophenolate mofetil (side effects: infection, anemia, leukopenia, and diarrhea). Regular blood tests are necessary to screen for hematological, hepatic and renal side effects. The first biologic, the interleukin (IL)4/13 receptor antagonist dupilumab, has been approved in ages >=12 years and is sometimes used off-label in early childhood9. Its main side effects are eye inflammation (including non-infectious conjunctivitis and blepharitis), injection site reactions, and herpes simplex virus infections.
Systemic corticosteroids are not recommended because of side effects (e.g. growth impairment) and risk of rebound after discontinuation. Antibiotics should only be initiated systemically in cases of superinfection and not for the treatment of Staphylococcusaureus colonization. In cases of recurrent skin infections sodium hypochlorite can be added to the bathwater (‘bleach bath’ with 1 mL of 5% household bleach per 1 L of water), however, recent data on efficacy are conflicting 10. Long-term daily use of sedating antihistamines in childhood may affect sleep quality and is not recommended. In some countries, melatonin is used to improve sleep quality. A therapeutic algorithm is presented in Figure I.
The algorithms (part I and part II) summarize the current standards for diagnosis and therapy of AD, however, the landscape is changing rapidly, especially for new therapeutic options. Dupilumab is currently the only biological approved for ages >= 12 years, with trials in younger children underway. Also, other drug classes are currently under investigation (e.g. janus-kinase and phosphodiesterase inhibitors for topical and systemic use). Given the special pace of innovation in AD treatment, the future is bright for young children with severe atopic dermatitis!
Table 1 – Discussion of the therapeutic options mentioned in the algorithm for the treatment of Atopic Dermatitis (AD) in early childhood