Summarizing Topical Options: Treating Atopic Dermatitis (AD) Across Every Age
A panelist discusses how topical treatments for atopic dermatitis can be strategically selected and applied across the lifespan, with considerations for age-specific needs from infancy through adulthood.
Summarizing Topical Options: Treating Atopic Dermatitis (AD) Across Every Age
First-Line Therapies
Emollients and Moisturizers
- Foundation of all AD management regardless of age
- Apply 2-3 times daily, especially after bathing
- Ceramide-containing formulations may provide superior barrier repair
- Ointments preferred for severe dryness; creams and lotions for better cosmetic acceptability
Topical Corticosteroids (TCS)
- Potency selection based on age, location, and severity
- Infants: Low potency only (hydrocortisone 1-2.5%)
- Children: Low to mid-potency for body; low potency for face/intertriginous areas
- Adolescents/Adults: Full potency range appropriate with location-based selection
- Apply once or twice daily during flares
- Proactive twice-weekly application reduces relapse rates
Second-Line Therapies
Topical Calcineurin Inhibitors (TCIs)
- Tacrolimus 0.03% (ages ≥2) and 0.1% (ages ≥16)
- Pimecrolimus 1% (ages ≥2)
- Preferred for face, neck, and intertriginous areas across all age groups
- No risk of skin atrophy; suitable for long-term maintenance
- Initial application burning more pronounced in younger patients
Phosphodiesterase-4 (PDE4) Inhibitors
- Crisaborole 2% ointment approved for ages ≥3 months
- Apply twice daily to affected areas
- Well-tolerated in pediatric populations
- Useful for steroid-sensitive locations
- Consider for maintenance therapy after flare control with TCS
Emerging Options
Topical JAK Inhibitors
- Ruxolitinib 1.5% cream approved for ages ≥12 years
- Not approved for immunocompromised patients
- Rapid itch relief (within 8-12 hours)
- Limited to ≤20% BSA application
- Not recommended for children <12 years pending additional safety data
Antimicrobial Approaches
- Reserved for clinically infected lesions
- Bleach baths (0.005-0.0125%) twice weekly beneficial across all ages
- Antiseptic washes may help manage bacterial colonization
- Antibiotic-containing combination products only for short-term use
Age-Specific Considerations
Infants (0-2 years)
- Emphasize non-pharmacologic approaches
- Limited use of TCS (low potency only)
- Careful attention to application amounts
- Wet wrap therapy effective for severe flares
- Avoid TCIs under age 2 (off-label if used)
Children (2-12 years)
- Education on self-care increasingly important
- Monitor for growth effects with potent TCS
- TCIs and PDE4 inhibitors particularly valuable
- School considerations (treatment timing, stigma)
- Simplified regimens to improve adherence
Adolescents (12-18 years)
- Vehicle selection critical for adherence
- Cosmetically acceptable options for visible areas
- Transition to self-management with supervision
- Consider impact on social development
- Attention to treatment burden during school/activities
Adults (>18 years)
- Occupational considerations for hand dermatitis
- Treatment of specific distribution patterns (head/neck, hand/foot)
- Pregnancy considerations for reproductive-age women
- Focus on long-term maintenance strategies
- Cosmetic aspects may drive vehicle preferences
Practical Treatment Strategies
- "Weekend therapy" maintenance regimen for all ages
- Step-up/step-down approaches based on disease activity
- Rotation between different agent classes for recalcitrant areas
- Written action plans for flare management
- Regular reassessment of treatment effectiveness and side effects
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