Educating Parents on Atopic Dermatitis in Children

Atopic dermatitis (AD) affects up to 24% of pediatric populations in the United States, with the highest rates observed among children 0 to 5 years of age, according to a 2021 review.¹ Many recent studies have focused on AD in children and adolescents, ranging from randomized clinical trials (RCTs) comparing treatment approaches to research highlighting the negative impact of AD on quality of life, academic performance, and psychosocial functioning in these populations.^2-4

Treatment of AD in pediatric patients presents unique challenges and requires collaboration with the patient’s parents and caregivers. In a JAMA Pediatrics Patient Page published in September 2022, researchers provided an overview intended to educate parents about the appearance, symptoms, triggers, and treatment options for AD in children.⁵

Key points from the paper are highlighted here:

• Many patients with AD have a family history of the disease as well as low levels of filaggrin, the protein that helps skin retain moisture and provides protection from irritating substances. Thus, AD patients have an increased risk for developing bacterial and viral cutaneous infections.⁵
• Infants often present with dry, itchy, inflamed skin on the face, scalp, trunk, arms, and legs, while children tend to develop lesions in the ankle area and creases of the elbow, knee, and neck. The lightness and darkness of lesions can vary depending on the individual’s skin tone. The presence of these features is typically sufficient for AD diagnosis, with no laboratory testing needed.  AD is not contagious and does not require absence from school. ⁵   

• AD flare-ups may result from stress, environmental factors such as allergens and changes in temperature and humidity, or exposure to irritants including cigarette smoke and scented products like soaps and detergents. Eliminating contact with such substances and using a moisturizer to repair the skin barrier are the first steps in AD treatment. Additional recommendations for all AD patients include a daily lukewarm bath or shower and use of a thick, fragrance-free and dye-free moisturizer at least twice each day, including after bathing.⁵ 
• Depending on the severity of disease, other treatment strategies may include over-the-counter or prescription creams or ointments, taking a diluted bleach bath 2-3 times weekly, or using oral or injectable medications. For the one-third of patients with other allergic disorders such as asthma or food allergies, immunotherapy may lead to improvement in AD symptoms.⁵

Recent Findings and FDA Approvals

In a randomized, phase 4 trial published in May 2022, the 4 main types of emollients used in pediatric AD — ointments, lotions, creams, and gels — showed no significant difference in clinical effectiveness or number of adverse effects in children aged 6 months to 12 years. However, stinging occurred less commonly with the use of ointments (9%) compared with the other emollient types (20%, 17%, and 19%, respectively).⁶

In June 2022, the US Food and Drug Administration approved the fully humanized monoclonal antibody dupilumab as the first and only biologic therapy for treating moderate to severe AD in children aged 6 months to 5 years who cannot use topical prescription treatments or have not shown an adequate response to these therapies.⁷

The oral JAK1 inhibitor upadacitinib was approved by the FDA in January 2022 for treatment of refractory, moderate to severe AD in adults and children aged 12 years and older.⁸

Among other promising therapies, in the phase 3 JADE TEEN trial of 285 adolescents with moderate-to-severe AD, the oral JAK1 inhibitor abrocitinib combined with topical therapy demonstrated significantly greater efficacy than placebo combined with topical therapy. Additionally, the abrocitinib combination showed an acceptable safety profile, with serious adverse events affecting less than 3% of patients.⁹

Although an estimated 75% of childhood-onset AD cases spontaneously resolve before adolescence, approximately 25% of cases will recur or persist into adulthood.¹

We checked in with Emily Gurnee, MD, dermatologist at Children’s Hospital Colorado and assistant professor at the University of Colorado, School of Medicine in Aurora, for further discussion about treating AD specifically in children.

What are some common challenges in treating AD in children vs adults?

Making a plan with a family to treat a child’s AD can be very complex. When deciding on treatments, providers have to consider safety and tolerability of products, issues with sleep, school performance, childcare arrangements, social interactions with other children, and parents’ schedules.

What are the standard treatment approaches for AD in children?

Most patients with AD benefit from frequent skin moisturization and avoidance of irritants.

Topical steroids have been used for years to treat AD in children and represent the mainstay of treatment for mild to moderate disease. Parents may have concerns about using topical steroids, particularly in young infants, so a detailed discussion about the safety of these products is often important for families to feel comfortable using them.  

Over the past few years, many new nonsteroid topical products have entered the market, but many have the disadvantage of burning and stinging. It is difficult enough to apply topical medications in young children, so tolerability is essential. For moderate-to-severe disease, dupilumab is now available in infants and children age 6 months and older, as well as the first FDA-approved oral JAK inhibitor for children 12 and older.^7,8

What other conditions might parents mistake AD for in children, and how might this exacerbate the condition?

AD is very common in children, particularly in babies and toddlers, so parents’ intuition is often correct if they suspect their child has AD. Many parents share concerns that certain formulas, foods ingested by breastfeeding parent, or solids fed to their child could be causing the AD. In general, it is very rare for AD to be triggered by ingestion of foods. In fact, elimination diets in infants and young children can be harmful in many ways, including impacts on growth and nutrition and increased risk of more serious allergic reactions.

There is increasing data on the importance of early introduction of high allergy foods to reduce the risk of allergy in infants with moderate to severe atopic dermatitis.¹⁰ Of course, if there is a concern about a food causing an immediate reaction to a food, urticaria, or any systemic symptoms, patients need further evaluation.

Many parents question whether products they use on their child’s skin, such as soaps, lotions, laundry detergents, or prescription topical medications may contribute to their child’s AD. Allergic contact dermatitis is probably about as common in children as adults, but children are much less likely to be tested for it. Diagnosing allergic contact dermatitis in the setting of AD is challenging and requires a high index of suspicion.

Tinea corporis is another common scaly rash seen in young children, and it can worsen with topical steroid medications.

What key takeaways should clinicians provide to parents to help manage AD in children?

Many clinicians undertreat AD due to concerns about the potential for local side effects with topical steroids. Instead of telling parents to use topical medications for a specific duration, I emphasize to parents that I expect lesions to improve within 1 to 2 weeks of use, and they can then temporarily discontinue treatments and focus on skin hydration. If there is no improvement after 1 to 2 weeks using prescribed products, patients should return for re-evaluation.

Caring for a child with AD is a lot of work and impacts the entire family in many ways, so our recommendations need to fit into the family’s schedule.

Ask families about burning or stinging with topical products for their child. Parents will understandably be hesitant to use products that their child finds painful.

In addition, primary care doctors can partner in discussing early introduction of high allergy foods in infants with AD.