Managing atopic dermatitis in infants

Anna Whalen-Browne; Hywel C. Williams; Derek K. Chu

doi:10.1503/cmaj.212094

In infants, atopic dermatitis most commonly involves the cheeks, outer limbs and trunk

Classical flexural involvement may not develop until later in childhood. Other transient forms of dermatitis, including irritant dermatitis and seborrheic dermatitis, should be differentiated from atopic dermatitis.1

The best moisturizer is the one that patients will use

New evidence has shown that, applied twice daily and as required, any class of emollient (i.e., lotion, cream, gel or ointment) can help manage atopic dermatitis and prevent flares.2 Bath emollient additives do not add benefit beyond direct skin moisturization; however, emollients can be used as soap substitutes.3

Atopic dermatitis requires anti-inflammatory treatment

The lowest effective strength of topical corticosteroid should be used. Applying treatment once daily is almost as effective as applying twice daily, and can improve adherence and reduce adverse effects and costs.1 A reactive approach — anti-inflammatory treatment during a flare until the skin is clear — is appropriate for mild atopic dermatitis. Relapsing or persistent cases may require a “get control and keep control” approach by inducing complete remission with application of a moderate (e.g., betamethasone valerate 0.05%) or potent (e.g., mometasone furoate 0.1%) topical corticosteroid to affected areas of the body (potent treatments should not by applied to the face), followed by about 3 months of treatment with moderate-potency corticosteroids or topical pimecrolimus for 2 consecutive days each week (e.g., on weekends).1

Treatment of secondary bacterial infection should focus on the underlying skin inflammation

Skin colonization or infection with Staphylococcal aureus is common, but evidence does not support the routine use of topical or oral antibiotics, which may contribute to antibiotic resistance.4 Oral antibiotics are only needed if systemic infectious signs such as fever are present.4

Food avoidance may not improve atopic dermatitis and risks promoting food allergy

Early introduction of allergenic foods to an infant may reduce the risk of developing food allergies.5 The Canadian Paediatric Society now recommends introduction of allergenic foods at about 6 months of age with continuation of breastfeeding to 2 years or longer, if possible. (https://cps.ca/en/documents/position/dietary-exposures-and-allergy-prevention).

Acknowledgements

The authors thank their patient and caregiver partners, and colleagues in pediatrics and family medicine for their feedback on earlier versions of this manuscript.

Footnotes

Competing interests: Hywel Williams is the founder of Cochrane Skin and network chair of the UK Dermatology Clinical Trials Network. Derek Chu is the 2022 atopic dermatitis guideline co-chair with the American Academy of Allergy, Asthma & Immunology (AAAAI) and the American College of Allergy, Asthma & Immunology. He is supported by the AAAAI Foundation, and previously, by funding from the Canadian Allergy, Asthma, and Immunology Foundation; the Canadian Society of Allergy and Clinical Immunology; and AllerGen NCE (via Government of Canada). No other competing interests were declared.
This article has been peer reviewed.

This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY-NC-ND 4.0) licence, which permits use, distribution and reproduction in any medium, provided that the original publication is properly cited, the use is noncommercial (i.e., research or educational use), and no modifications or adaptations are made. See: https://creativecommons.org/licenses/by-nc-nd/4.0/

References

↵
1. Schneider L,
2. Tilles S,
3. Lio P,
4. et al
. Atopic dermatitis: a practice parameter update 2012. J Allergy Clin Immunol 2013;131:295–9 e1–27.
OpenUrl CrossRef PubMed
↵
1. Ridd MJ,
2. Santer M,
3. MacNeill SJ,
4. et al
. Effectiveness and safety of lotion, cream, gel, and ointment emollients for childhood eczema: a pragmatic, randomised, phase 4, superiority trial. Lancet Child Adolesc Health 2022;6:522–32.
OpenUrl
↵
1. Santer M,
2. Ridd MJ,
3. Francis NA,
4. et al
. Emollient bath additives for the treatment of childhood eczema (BATHE): multicentre pragmatic parallel group randomised controlled trial of clinical and cost effectiveness. BMJ 2018;361:k1332.
OpenUrl Abstract/FREE Full Text
↵
1. George SMC,
2. Karanovic S,
3. Harrison DA,
4. et al
. Interventions to reduce Staphylococcus aureus in the management of eczema. Cochrane Database Syst Rev 2019;(10)CD003871.
↵
1. Oykhman P,
2. Dookie J,
3. Al-Rammahy H,
4. et al
. Dietary elimination for the treatment of atopic dermatitis: a systematic review and meta-analysis [preprint]. J Allergy Clin Immunol Pract Epub 2022 July 19. Available: https://www.sciencedirect.com/science/article/abs/pii/S2213219822006936 (accessed 2022 Aug. 18).