Alternative treatments. A number of alternative measures purport to reduce a child’s risk of developing AD and/or reduce its severity (TABLE), but in most cases, evidence is lacking.
Consider systemic treatment for refractory AD
In a subgroup of patients with moderate to severe AD, the condition is refractory to standard topical therapy and systemic treatment is required. Systemic treatments—including oral corticosteroids, cyclosporine, mycophenolate mofetil, azathioprine, methotrexate, and interferon—should be undertaken only under supervision of a dermatologist.
Oral corticosteroids (typically, prednisone) are sometimes used for short-term treatment of severe AD, although rarely for young children. Evidence of their efficacy is insufficient, and their use is controversial. Patients may have severe symptom flares when an oral corticosteroid is tapered or discontinued. And no randomized controlled trials of prednisone therapy for AD were found in the peer-reviewed medical literature, despite the drug’s long-standing use in AD treatment.30
Systemic immunomodulatory therapies such as cyclosporine, azathioprine, interferon gamma, intravenous immune globulin, mycophenolate, and infliximab have been used for recalcitrant AD. Cyclosporine, an immunosuppressant that acts directly on the cells of the immune system and has an inhibitory effect on T cells, decreases AD severity in the short term. Cyclosporine has been found to be safe, effective, and well tolerated in children with AD, but the potential for hypertension and renal toxicity limits its usefulness for long-term therapy.30
Other systemic immunomodulatory therapies, including those listed above, should be considered when cyclosporine is contraindicated or does not produce a suitable response. Prospective controlled trials in a pediatric population are needed to evaluate the long-term effectiveness and safety of other agents.
Phototherapy is another option
Phototherapy has evolved as a treatment for recalcitrant AD, based on the observation that the condition often improves during the summer months with increased exposure to natural light. Adverse effects of phototherapy can include erythema, pruritus, and pigment changes. Ultraviolet light is also known to cause premature aging of the skin, as well as cutaneous malignancies.4,10,14 Therefore, phototherapy, like systemic treatment, should be undertaken only with the supervision of a dermatologist.
When infection complicates care
Colonization with Staphylococcus aureus is common in patients with AD. In addition to contributing to pruritus and chronic inflammation, S aureus is a risk factor for infection.
Treatment with topical or systemic antibiotics has no clear benefit for patients with AD, except when skin infection is present, When there is evidence of infection, however, methicillin-resistant S aureus must be considered, and any abscess incised and drained.1
Herpes simplex virus infection, another possibility in patients with AD, should be treated immediately with antiviral therapy. If the lesions are widely distributed or the patient has a toxic appearance, hospitalization and IV therapy is warranted—as is an ophthalmology consult when eye or periocular involvement is suspected.1,9
Dermatophyte infections are also more common in patients with AD and can be treated with standard regimens of topical or oral antifungals. Fungi may play a role in chronic inflammation; if there is no infection, however, patients respond better to anti-inflammatory agents than to antifungals.1
Time for a referral
As already noted, a dermatology consult is indicated for refractory AD and when systemic treatment and/or phototherapy is being considered. The suspicion of eczema herpeticum indicates a need for an immediate dermatology referral. An urgent referral is needed for patients with severe AD that has not responded to a week of optimum topical therapy—or whose treatment of bacterial infection has failed. Consider a dermatology consult, as well, when the diagnosis is uncertain or the patient’s symptoms have been poorly controlled. If you (or the child’s parents) suspect that a food allergy is the cause of a severe case of AD, a referral to an allergist is recommended.6,19,21,22
CASE 1 Dylan’s mother calls to tell you that, to her surprise, his eczema has completely cleared up, even though she did not change his formula. You advise her to continue to use the emollient at least twice a day and to bring him in if he develops another flare.
CASE 2 Two weeks after Angela’s office visit, her mother calls to report that her daughter has responded well to triamcinolone ointment 0.025%, the topical steroid you prescribed. When Angela comes in for a well-child visit at age 2, however, she has a mild flare. You prescribe a brief course of triamcinolone ointment and remind her mother to be diligent about skin care.