Management of Severe Atopic Dermatitis in Children
October 2012 | Volume 11 | Issue 10 | Original Article | 1158 | Copyright © 2012
Severe childhood atopic dermatitis refers to the presence of recurrent, widespread, eczematous dermatitis that significantly interferes with the daily activities and/or the quality of life of the affected child and family. The vast majority of children with severe, long-standing atopic dermatitis can be managed with the appropriate use of topical treatments, including long-term maintenance therapy and adjunctive treatments. In the recalcitrant patient, second line therapies such as narrowband ultraviolet light therapy and systemic immunosuppressants such as cyclosporine, azathioprine, mycophenolate moefetil, and methotrexate have been shown to be safe and effective in children with severe atopic dermatitis and can lead to sustained clinical improvement. To date, biologic therapy has not been uniformly effective in childhood atopic dermatitis. Management of severe childhood atopic dermatitis, including topical and adjunctive treatments and second-line therapies including systemic immunosuppressants will be reviewed here.
J Drugs Dermatol. 2012;11(10):1158-1165.
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Atopic dermatitis (AD) is a common, chronic inflammatory skin disease that presents with markedly pruritic eczematous lesions in highly characteristic distribution patterns in infants and children. Symptoms begin during infancy (usually after 2 months) in more than half of patients, and the onset is before 5 years of age in 90% of patients. Atopic dermatitis affects 10% to 20% of children worldwide, making it the most common chronic pediatric skin condition and data suggests an increasing prevalence over the past several decades in some countries.1,2 Atopic dermatitis has a substantial adverse impact on the quality of life of affected children and the societal economic burden is high.3,4 The pathogenesis of AD involves cutaneous immune dysregulation and defects in the epidermal barrier and treatment should address both these facets.5
Severe AD has been defined by using clinical severity scores such as the Severity Scoring of Atopic Dermatitis (SCORAD) index or the Eczema Area and Severity Index (EASI), which are useful for standardizing results in clinical trials, but are not routinely used in clinical practice.6 Rather, in clinical practice, severe AD refers to the presence of widespread eczematous dermatitis that significantly interferes with daily activities and/or the quality of life of the affected child and family. In the vast majority of children with severe widespread atopic dermatitis, even if it has been long-standing, the condition can be managed with the appropriate use of topical treatments (Figure 1).
Appropriate Use of Topical Corticosteroids and Long-Term Maintenance Therapy
Topically applied corticosteroids to areas of active dermatitis together with emollients to all skin are the mainstay of AD therapy. When used appropriately, topical corticosteroids can clear even the most severely affected patient. When treating children with severe AD there is an added challenge of communicating and educating an often frustrated parent or family to ensure that they understand the reasons for and how to properly use prescribed treatments.
The appropriate use of topical corticosteroids involves using a sufficient potency to clear the eczematous dermatitis completely in a reasonable amount of time. It can be helpful to find an area on the child's skin that is free of dermatitis to show the patient and parent what "clear" means (ie, no longer red, rough, or itchy). Patients and parents should be instructed to continue to use the topical corticosteroid twice daily until the skin feels completely smooth and then continue its use for one to two more days after that. Families are often given a time point to discontinue the topical corticosteroid, which results in incomplete treatment and a shorter time to recurrence. In addition, stressing that a topical steroid must only be used for 7 days may contribute to parental “steroid phobia,” a major cause of parental anxiety and lack of adherence.7 The amount of topical medication necessary to treat the affected area(s) should be explicitly discussed and, if possible, demonstrated. Enough medication should be used to cover the entire affected area with a thin layer. The concurrent use of proper emollients (ie, fragrance-free, ceramide-based creams, or ointments) should be re-emphasized. Lastly, explicit written instructions and close follow-up within 1 to 3 weeks are essential to assure correct use of treatments and to evaluate progress.
The initial follow-up visit after an acute severe flare is also a time to further educate the patient and family on AD, its chronic nature and the importance of long-term maintenance treatment. Long-term maintenance must be a part of treatment for all patients with AD whether they have mild, moderate or severe disease. For severe recurrent AD, maintenance with intermittent mid-potency topical corticosteroids (ie, fluticasone) or topical calcineurin inhibitors 2 to 3 times weekly to eczema prone areas during periods of good control, in addition to daily use of emollients on all skin reduces the frequency and severity of flares.8