Non-topical management of recalcitrant paediatric atopic dermatitis

Abstract

Atopic dermatitis (AD) is a common chronic, pruritic skin disease in children. As the incidence of AD increases, especially in high-income countries, paediatricians may see an increasing number of recalcitrant AD cases in their practice. Although these cases are principally managed by paediatric dermatologists, it is important for paediatricians to be aware of the use and side effects of non-topical treatment like phototherapy and systemic agents as well as the evidence for alternative treatment, which caregivers may ask about. This review presents paediatric evidence for the practical use of phototherapy and certain oral immunosuppressants for paediatric AD including doses, duration of use and monitoring of adverse effects. The use of alternative therapy including traditional medicine, probiotics and the role of nutrition are also discussed. Narrow band ultraviolet B phototherapy is effective in recalcitrant paediatric AD. When phototherapy is ineffective or contraindicated, systemic drugs may be administered cautiously with close surveillance of side effects. The use of azathioprine, ciclosporin, methotrexate and mycophenolate mofetil is generally safe in the short term under close monitoring and can be effective alongside compliance to topical treatment. Alternative complementary treatment is not known to be effective. Holistic management including therapeutic patient education is important. Good quality paediatric studies for non-topical AD treatment are needed for definitive guidelines.

Atopic dermatitis in children: when topical steroid treatment “does not work”

“…Refer patients who do not show clinical improvement or who experience frequent, severe flares while on confirmed, adequate therapy—or patients for whom the diagnosis is unclear, especially if the lesions look atypical—to a paediatric dermatologist or paediatrician to consider the use of second line therapy such as phototherapy or immunosuppresants43 or to explore alternative diagnoses.…”

Topical and Oral Therapies for Childhood Atopic Dermatitis and Plaque Psoriasis

“…Azathioprine (Az) is an inhibitor of purine synthesis that reduces leukocyte proliferation and can be used for severe or refractory AD [47,48]. A small study reported clinical improvement, without quantification, in 11 of 12 pediatric patients with recalcitrant AD treated with Az and few AEs [47]. The catabolism and active metabolite production of Az is carried out by the enzyme thiopurine methyltransferase (TPMT).…”

Patient Journey in Atopic Dermatitis: The Real-World Scenario

“…Irrespective of specific recommendations regarding nonpharmacological therapy, various authors have highlighted the need to promote the involvement of patients in their treatment [23][24][25]. We found a strong consensus on the need for patients to be committed to their therapy (82% agreement), and the need to provide patients with educational measures to achieve patient commitment (65% agreement).…”