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