Summarizing Topical Options: Treating Atopic Dermatitis (AD) Across Every Age

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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.

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      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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