The American Academy of Dermatology (AAD) has published two companion guidelines addressing pediatric atopic dermatitis: one focused on medical treatment and another on primary prevention and comorbidity awareness. Together, the guidelines include 27 treatment recommendations, 14 prevention recommendations, and 29 statements describing associations between AD and comorbid conditions in patients younger than 18 years.
Both guidelines were developed by a multidisciplinary workgroup using systematic evidence review and the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) framework. The treatment guideline evaluated topical therapies, phototherapy, and systemic agents, while the prevention guideline focused on infant-directed interventions and evidence linking atopic dermatitis (AD) with comorbidities.
Topical Therapies
The workgroup made strong recommendations for several therapies, supported by moderate- to high-certainty evidence. These include moisturizers, topical calcineurin inhibitors (TCIs), topical corticosteroids (TCS), crisaborole, roflumilast, ruxolitinib, and tapinarof.
Moisturizers remain foundational. Across 9 randomized controlled trials involving 1,260 pediatric patients, they reduced disease severity and improved clinical outcomes, although no specific formulation or ingredient could be recommended.
TCIs—tacrolimus and pimecrolimus—were strongly recommended for both active treatment and proactive maintenance. Evidence for pimecrolimus drew from 8 trials (2,637 patients) showed improved rates of clear or almost clear skin, with no demonstrated causal link to malignancy despite longstanding boxed warnings.
Topical corticosteroids continue to serve as first-line therapy due to their efficacy, accessibility, and long safety track record. The guideline emphasizes tailoring potency to anatomical site and supports intermittent use of low- to medium-potency steroids for maintenance therapy up to three times weekly.
Among newer nonsteroidal agents, roflumilast and ruxolitinib demonstrated strong efficacy. In pooled trials, roflumilast doubled the likelihood of achieving EASI 75 compared with vehicle and showed favorable tolerability. Ruxolitinib produced comparable efficacy to potent corticosteroids and tacrolimus, though its use should be limited to at least 20% body surface area due to systemic absorption concerns and class-related boxed warnings.
Tapinarof, a first-in-class aryl hydrocarbon receptor agonist, also showed significant improvements in disease severity and itch, with modest increases in follicular adverse events.
Topical antimicrobials were conditionally recommended against in patients without signs of infection, reflecting limited benefit and antimicrobial stewardship concerns.
Adjunctive Measures
Bathing received a conditional recommendation, although evidence was insufficient to define optimal frequency or duration. Dilute bleach baths may improve clinician-assessed severity but have limited impact on patient-reported outcomes. Wet wrap therapy was also conditionally recommended, particularly during flares.
Phototherapy and Systemic Therapies
Phototherapy received a conditional recommendation based on low-certainty evidence, with limited pediatric-specific data available. PUVA phototherapy was conditionally recommended against due to long-term safety risks, including skin cancer.
Biologic therapies have significantly expanded treatment options for moderate-to-severe disease. Dupilumab received a strong recommendation for patients as young as 6 months, with consistent improvements in disease severity, itch, and quality of life. Conjunctivitis remains a notable adverse event.
Tralokinumab and lebrikizumab, both targeting IL-13, and nemolizumab, targeting IL-31, were also strongly recommended for patients aged 12 years and older. All demonstrated meaningful improvements in clinical outcomes with acceptable safety profiles.
Oral Janus kinase inhibitors (JAK inhibitors) upadacitinib and abrocitinib were strongly recommended for patients aged 12 years and older with inadequate response to other systemic therapies. Baricitinib received a similar recommendation, although it is not FDA-approved for AD in the United States.
Traditional immunosuppressants—including methotrexate, mycophenolate mofetil, azathioprine, and cyclosporine—were conditionally recommended for refractory disease. Systemic corticosteroids were strongly discouraged for maintenance use and reserved only for short-term management of severe flares.
Primary Prevention
The prevention guideline focuses on early-life interventions. Regular use of moisturizing skin care before age 2 in high-risk infants received a conditional recommendation, with evidence suggesting a reduction in AD development.
In contrast, early food introduction, human milk consumption, probiotic supplementation, and vitamin D supplementation were conditionally recommended against due to lack of demonstrated benefit. Evidence was insufficient to support environmental interventions such as dust mite avoidance or water softening.
Comorbidities
The guideline does not make recommendations for screening or management of comorbidities but instead summarizes evidence on associations to improve clinical awareness.
Moderate-certainty evidence supports associations between pediatric AD and allergic rhinitis, asthma, food allergies, urticaria, attention deficit hyperactivity disorder, and skin infections. AD was also associated with eosinophilic esophagitis with high certainty.
AD is probably associated with anxiety and obesity, while associations with depression and autism spectrum disorder remain uncertain. The condition was not associated with substance use, cardiovascular disease outcomes such as heart failure or arrhythmia, or diabetes, though the associations with hypertension and ischemic heart disease remain uncertain or of small magnitude.
Notably, the prevalence of asthma and food allergy increased with AD severity, underscoring the importance of disease control.
Gaps and Limitations
The workgroup highlighted several research gaps, including the need for head-to-head comparisons between newer targeted therapies and traditional treatments, better characterization of optimal moisturizer formulations, and more pediatric-specific data for older systemic agents.
Short trial durations limit long-term safety and efficacy conclusions, and cost remains a significant barrier for newer biologic and targeted therapies.
Conclusion
The guidelines emphasize a rapidly evolving treatment landscape, while noting limitations in long-term data, and reinforce the continued role of established therapies. With expanding options—including biologics and oral JAK inhibitors—the workgroup underscores the importance of individualized, shared decision-making to balance efficacy, safety, accessibility, and patient preferences.
The full guidelines, including supplementary tables and methodology, are published in the Journal of the American Academy of Dermatology. The treatment guideline is available at doi.org/10.1016/j.jaad.2026.02.113 and the prevention and comorbidities guideline at doi.org/10.1016/j.jaad.2026.02.114.
Disclosures: Multiple workgroup members reported financial relationships with pharmaceutical manufacturers, including Regeneron, Sanofi, AbbVie, Pfizer, Eli Lilly, LEO Pharma, Galderma, Arcutis, Incyte, Dermavant, and others, in the form of research grants, consulting fees, honoraria, or stock options. Full disclosures are available in the source articles. Drs Alikhan, Bercovitch, Davis, Frazer-Green, and Darr reported no relevant relationships.
