1 Faculty of Medicine, University of British Columbia, Vancouver, BC. 2Clinical Associate Professor, Department of Pediatrics, Associate Member, Department of Dermatology and Skin Sciences, University of British Columbia, Vancouver, BC.
Abstract: Atopic dermatitis is a common pediatric disease with a chronic relapsing-remitting course, causing distress to patients and family. In patients who remain recalcitrant following treatment with topical steroids, adjunctive therapies including bleach baths, wet wraps and phototherapy as well as systemic immunosuppressants may be considered. Many novel therapies are in development and act on various aspects of the immunologic cascades involved in atopic dermatitis. The following review briefly summarizes up-to-date evidence for the use of these therapies in the pediatric population.
Topical corticosteroids, the first-line treatment for atopic dermatitis, can be optimized with usage of an appropriate amount and within a supportive, therapeutic alliance.
Those who fail to improve with topical corticosteroids may benefit from adjunctive treatment with wet wraps, bleach baths and phototherapy with narrowband UV therapy. These have been shown to be efficacious with a minimal side effect profile.
In those who remain recalcitrant, a brief course of immunosuppressants may be indicated. Methotrexate, azathioprine and cyclosporine have evidence in the pediatric population. Of these, methotrexate has been shown to have the most sustained duration of remission.
A recent explosion of novel immunomodulators and biologics may redefine atopic dermatitis treatment. Crisaborole is a topical PDE4 inhibitor, which has been approved for used in children. Dupilumab is an injectable monoclonal antibody, which has recently been approved for the adult population and remains off-label in pediatrics.
Monotherapy when possible and regular check-ins with parents can improve adherence to topical steroid regimens, particularly within the first 3 days of treatment.
The American Academy of Dermatology recommends the use of bleach baths (1/2 cup of 6% household bleach in a 150L bathtub full of water) for 5 to 10-minute intervals 2-3 times weekly as an adjunct to topicals.
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