The American Academy of Pediatrics has published updated clinical guidelines for the management of atopic dermatitis, a chronic condition that affects 20% to 25% of pediatric patients and significantly impacts the quality of life for both patients and families.
The updated guidelines present a comprehensive approach to skin-directed care, incorporating recent advances in understanding the pathophysiology, psychosocial effects, and treatment of this common pediatric disease.
“Atopic dermatitis (AD) impacts quality of life in multiple domains in affected children and their families,” the guideline authors noted. “Itching, treatment burden, sleep, embarrassment related to appearance of the skin, and ability to participate in sports have the most bearing on quality of life.” Sleep disturbance affects approximately two-thirds of pediatric patients, and sleep disruption is associated with anxiety, depression, and inattention.
Pathogenesis and Treatment Foundations
The guideline report, led by Jennifer J. Schoch, MD, of the American Academy of Pediatrics (AAP) Section on Dermatology, emphasized the role of skin barrier dysfunction, immune dysregulation (notably Th2 polarization), and microbiome alterations in AD pathogenesis. This framework underlies current and emerging treatment approaches.
Core Treatment Principles
The AAP noted three foundational pillars of treatment:
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Maintenance skin care: Daily moisturization enhances skin barrier function and helps reduce flare frequency. Moisturizers should be fragrance-free, thick in texture, and applied liberally, particularly after bathing. However, routine use of prophylactic emollients for AD prevention is not supported. “In the BEEP and PreventADALL studies, two large randomized controlled trials, there was no statistically significant change in incidence of AD in those who were treated with daily emollient vs those that used only routine infant skin care,” the guideline authors noted.
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Topical anti-inflammatory medications: Topical corticosteroids remain the standard of care for active disease. The guideline authors addressed common misconceptions, stating: “Although rare cases of hypopigmentation secondary to intralesional corticosteroid use have been reported, typical use of topical steroids does not alter skin pigmentation.”
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Trigger avoidance: Environmental triggers—such as irritants, low humidity, and allergens—can precipitate flares and should be avoided when possible.
They also recommended considering patch testing in patients with recalcitrant or atypical presentations of AD.
Proactive Therapy and Written Action Plans
Beyond reactive care, the AAP addressed the benefits of proactive treatment: applying topical corticosteroids or calcineurin inhibitors 2 to 3 times per week to previously affected areas—even when the skin appears clear—can reduce flare frequency and improve quality of life.
To support adherence, the AAP endorsed written action plans. These have been shown to improve treatment understanding and outcomes and are also helpful tools for clinicians. Adolescents were encouraged to participate in developing these plans to foster self-management.
Addressing Health Disparities and Comorbidities
The report underscored racial disparities in AD. Black infants may be more likely to develop AD, and both Black and Hispanic children tend to experience more severe disease. These groups could also be more likely to miss school as a result of AD and to receive care in primary or emergency settings, while being less likely to be referred to dermatology subspecialists.
Mental health implications were also emphasized. AD is associated with depression and anxiety in patients and caregivers. The report suggested behavioral strategies, including sleep hygiene and relaxation techniques, to manage sleep disturbances and psychological distress.
Clarifying Food Allergy and the LEAP Trial
The AAP that while AD and food allergies often co-occur, food-induced AD is rare. “Overemphasis on food allergy as a cause of AD leads to unnecessary, and potentially dangerous, elimination diets and may result in intolerance of previously tolerated foods,” they noted.
The guidelines incorporate findings from the LEAP trial and recommended early peanut introduction based on AD severity. For infants with severe AD, testing may be appropriate prior to peanut exposure; for those with mild to moderate disease, introduction around 6 months of age is advised.
New and Emerging Treatment Options
While traditional treatments remain effective, newer therapies have expanded the therapeutic landscape.
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Dupilumab is a monoclonal antibody targeting interleukin (IL)-4 and IL-13, approved among pediatric patients aged 6 months and older.
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The JAK inhibitors upadacitinib and abrocitinib are approved for pediatric patients aged 12 years and older with refractory moderate to severe AD.
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Topical ruxolitinib is a topical JAK inhibitor approved for patients aged 12 years and older.
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Crisaborole: A topical phosphodiesterase-4 (PDE4) inhibitor for mild to moderate AD, though the clinical benefit is modest and use may be limited by application-site stinging.
Additional therapies—including aryl hydrocarbon receptor agonists and new PDE4 inhibitors—are under development.
Infection Management and Preventive Care
The AAP also addressed managing infectious triggers, particularly Staphylococcus aureus, molluscum contagiosum, eczema herpeticum, and eczema coxsackium. Maintenance skin care, bleach baths (as tolerated), and proactive treatment reduce infection risk by supporting microbial diversity. Antibiotics are recommended only for clinically evident bacterial superinfection.
Conclusion
Core recommendations included daily moisturization, appropriate use of topical anti-inflammatory agents, and proactive therapy for flare prevention. Written action plans, attention to mental health, and equitable care were emphasized throughout. Subspecialist referral was advised for severe, treatment-refractory, or complicated cases.
Disclosures can be found in the published clinical report.
Source: Pediatrics