Managing atopic dermatitis in pediatric patients

Atopic dermatitis, a type of eczema, is a common chronic inflammatory skin condition that requires ongoing management. Treating atopic dermatitis requires a long-term care approach. Atopic dermatitis is often associated with intense pruritus, but also can be complicated by pain and secondary infection without proper treatment and intervention.

“Primary care providers must communicate to parents that atopic dermatitis is not curable but can be properly managed over time,” said Patricia S. Todd, M.D., pediatric dermatologist with Norton Children’s Dermatology, affiliated with the UofL School of Medicine. “Expectation-setting with parents from the outset of a diagnosis can help them better understand their child’s condition and improve adherence to a treatment plan.”

Medication treatment strategies
Short-term treatments, such as a one- or two-week course of topical steroids, may alleviate severe symptoms temporarily, but they are not a permanent solution. As a chronic condition, it can fluctuate over time, requiring different approaches based on the severity of symptoms.

When prescribing treatment, clarity is key. Misunderstandings about medication use are common and can lead to ineffective management of the condition or unwanted side effects. Provide detailed instructions for both flare and maintenance phases. Specify which medication to use, the exact dosage, the specific duration and the application areas.

For instance, instructing parents to “use triamcinolone 0.025% ointment for seven days on the rash on the arms” provides clear, actionable steps. Also, explaining what each medication is and its purpose (e.g., “Triamcinolone is a topical steroid, and mupirocin is a topical antibiotic.”) can further aid understanding and adherence.

Regular follow-ups can ensure the treatment plan is being followed correctly and facilitate any necessary adjustments based on symptoms. These check-ins can help clarify instructions, address confusion, reinforce the treatment plan and strengthen the patient-provider relationship.

Explore nonsteroid treatment options
As an alternative to topical steroids, there are several nonsteroidal options available to help with predominantly mild to moderate cases. These include calcineurin inhibitors (e.g., pimecrolimus, tacrolimus), phosphodiesterase 4 inhibitors (e.g., crisaborole) and Janus kinase inhibitors (e.g., ruxolitinib for patients ages 12 and older). Offering these alternatives can help reduce the dependency on topical steroids and, in some cases, provide more long-term management options for patients.

Develop a daily skincare routine

In addition to any medications, it is essential that patients follow a dry skincare routine to manage atopic dermatitis. This routine helps restore barrier function of the skin, a key pathophysiologic mechanism of the disease. Encourage daily or every-other-day bathing with lukewarm water for no more than 10 minutes to hydrate the skin without causing irritation. Soap should be used sparingly and only on areas that truly need it, such as the armpits, groin and feet. Nonsoap cleansers are preferable, as they have less impact on the skin’s pH and are less likely to exacerbate symptoms.

Emollients should be applied immediately after bathing, to lock in moisture. The best moisturizing emollients are those that are thick: they usually come in jars, such as petroleum jelly, which is a highly effective, safe and affordable product. Added ingredients, such as fragrance, should be avoided.

Proper use of topical steroids in atopic dermatitis and eczema

Topical corticosteroids are a key component of managing atopic dermatitis and other forms of eczema.
In recent years, there has been an increase in hesitancy surrounding these medications and their potential side effects. Common misconceptions about topical steroids include:

1. Topical steroids bleach the skin.

While topical steroids can cause hypopigmentation, it is rare and typically occurs only with significant overuse of higher-potency steroids. In most cases, lighter spots on the skin are a result of the eczema itself and are usually reversible.

2. Topical steroid addiction or withdrawal will occur if prescribed.

Risk of topical steroid addiction or topical steroid withdrawal is low if the medications are used as prescribed. It is important to educate and provide detailed instructions about the correct application, dosage, potency and duration of use.

Guidelines for safe topical steroid use

To ensure safe and effective use of topical corticosteroids in patients with atopic dermatitis, primary care providers should follow these guidelines:

1. Choose the right potency. Select the appropriate steroid potency based on the severity of the condition, the location of the rash and the patient’s age. Lower-potency steroids are preferred for sensitive areas and younger patients.
2. Educate on proper application. Instruct patients and caregivers to apply a thin layer of the steroid only to the affected areas, avoiding healthy skin. Emphasize the importance of washing hands after application to prevent accidental transfer to sensitive areas, such as the eyes.
3. Define treatment duration. Clearly outline the duration of steroid use and provide guidelines for when to stop or taper the medication. For example, a detailed regimen of daily use for a specified number of days followed by a gradual reduction can be effective in managing flares while minimizing risks.
4. Consider nonsteroidal alternatives. Consider incorporating nonsteroidal treatments, especially for sensitive areas or maintenance once flares are controlled.

Understanding the risks of topical corticosteroids

Side effects of topical steroids to recognize are skin atrophy and ocular toxicity.

Skin atrophy involves thinning and translucency of the skin, caused by steroids that are applied continuously, even after symptoms have improved. Atrophy is more likely to occur in areas with thinner skin, such as the face, neck, groin and armpits. Ocular toxicity can occur when topical steroids are applied around the eyes, increasing the risk for cataracts and glaucoma with prolonged use.

To help avoid topical steroid side effects, consider the following management strategies:

• Targeted application: Apply steroids only to affected areas and avoid unnecessary use.
• Setting specific timelines: Prescribe steroids for limited periods (e.g., seven to 10 days followed by every other day application for one to two weeks, followed by discontinuation) and advise against prolonged use without medical supervision.
• Monitoring for side effects: Regularly assess the skin for signs of atrophy and adjust the treatment plan as needed.
• Avoiding use around the eyes: Reserve steroids for other treatment areas and consider alternative, nonsteroidal therapies around the eye region.

 

Most cases of atopic dermatitis can be managed effectively in a primary care setting. Patients with more severe cases or families who exhibit hesitancy or resistance to treatment options should be referred to Norton Children’s Dermatology.