Pros and Cons of Treatments for Your Child’s Atopic Dermatitis

Many prescription treatment options work by blocking the immune responses that drive atopic dermatitis flares in different ways. Older and less specific ways of treating atopic dermatitis often aren't enough when the condition is moderate or more severe. Fortunately, you'll now have a growing number of newer and more targeted treatment options for atopic dermatitis that are approved for use in children or teens. Targeted treatment options include pills, topical creams, and injected or infused biologics. Your treatment options may include topical steroids and light therapy (phototherapy) along with drugs in different classes that work in different ways. Depending on how severe your child's atopic dermatitis is, their age, and other things, your options may include topicals and systemic medicines.

Systemic and topical medicines for atopic dermatitis in children include:

Interleukin (IL) inhibitors (biologics)

• Dupilumab (Dupixent)
• Lebrikizumab (Ebglyss)
• Nemolizumab (Nemluvio)
• Tralokinumab (Adbry)

Janus kinase (JAK) inhibitors

• Abrocitinib (Cibinqo)
• Ruxolitinib  (Opzelura)
• Upadacitinib (Rinvoq)

PDE inhibitors

• Crisaborole (Eucrisa)
• Roflumilast (Zoryve)

AhR agonists

• Tapinarof (Vtama)

Calcineurin inhibitors

• Pimecrolimus (Elidel)
• Tacrolimus (Protopic)

What Are Pros and Cons of Topical Corticosteroids for My Child’s Atopic Dermatitis?

Doctors consider topical treatments a mainstay of treatment for mild to moderate AD. You may use them along with other treatments, depending on how severe your child's skin condition is and how well they respond to topicals. Topicals can help with the inflammation and itching. But you'll need to take precautions. For example, you'll use them only in spots where your child has an active flare.

When you're using topical corticosteroids, it's important to keep your child's skin hydrated with moisturizers. Topical steroids come in different strengths and formulations that may have pros and cons. For example, steroids in ointments or creams have advantages because they keep the skin moist. But they have other downsides. For instance, they can block sweat glands, especially if you live in a place that's warm. Ask your doctor what kind of moisturizer and topical steroid formulation they recommend for your child's skin, including:

• Lotion
• Cream
• Gel
• Oil
• Ointment

You'll want to avoid products with ingredients that might irritate your child's delicate skin, such as:

• Preservatives
• Solubilizers
• Fragrances

While you're likely to try topical steroids first, they often won't be enough if your child's atopic dermatitis is moderate or severe. They also can come with complications if you use them for a long time. Complications may include:

• Skin atrophy
• Telangiectasia (small, dilated blood vessels on the skin's surface)
• Striae (stretch marks)
• Loss of skin color or pigment
• Corticosteroid acne

What Are Pros and Cons of Calcineurin Inhibitors?

Calcineurin inhibitors, including pimecrolimus (Elidel) cream and tacrolimus (Protopic) ointment, are more targeted topical treatments for atopic dermatitis. They work by blocking a protein called calcineurin that plays a role in inflammation. You're most likely to consider using these in the short term or as needed if your child's atopic dermatitis is more severe. They also may be a good option if you're worried about using topical corticosteroids for a long time.

Clinical studies show calcineurin inhibitors can improve symptoms in atopic dermatitis quickly. They may work when topical corticosteroids don't. They may cause your child to have a burning sensation, especially at first. There have been concerns that they could come with more risk of cancer. More study is needed to confirm that they're safe to use for long periods. Still, topical calcineurin inhibitors may be a good option if your child is at least 2 with a healthy immune system.

What Are Pros and Cons of PDE Inhibitors?

PDE inhibitors are another topical option for atopic dermatitis that's mild to moderate. They're called PDE inhibitors because they block an enzyme called phosphodiesterase 4 (PDE4). 

The PDE4 enzyme is involved in inflammation responses in your skin. When your child or teen has atopic dermatitis, this enzyme may be present at higher-than-normal levels or working too hard. By blocking its activity, it can help to reduce inflammation and eczema flares.

The PDE inhibitor crisaborole (Eucrisa) is approved to treat children as young as 3 months. Roflumilast (Zoryve) is a foam that works in the same way. It's approved for kids ages 6 and up. Studies show PDE inhibitors can help with redness and itching without significant side effects.

What Are Pros and Cons of AhR Agonists?

AhR stands for aryl hydrocarbon receptor. It's a topical treatment for atopic dermatitis that works by activating the AhR receptor. When this receptor is activated, it helps to reduce inflammation. It also increases the activity of proteins that are important for your skin barrier to work well. 

So far, tapinarof (Vtama) is the only medicine in this class. It's approved by the FDA for children ages 2 and up, but it doesn't work for everyone. It is used topically (on the skin) once a day. Tapinarof may come with side effects including:

• Folliculitis
• Headache
• Cold-like symptoms

If you'd like to try a targeted topical for your child's atopic dermatitis, ask your dermatologist which one they'd recommend trying first and why.

What Are Pros and Cons of Systemic Steroids for Atopic Dermatitis in Children?

Systemic steroids can help to calm severe atopic dermatitis. But doctors don't normally recommend them for children. That's because they come with serious side effects when taken for an extended time, including stunted growth and increasing the risk of infection by suppressing the immune system.

What Are Pros and Cons of IL Inhibitors for Atopic Dermatitis in Children?

IL is short for "interleukin." Interleukins are a type of cytokine or chemical signal your cells make. They are important for communication to cells in your immune system. They may signal immune cells to turn on or become more active. They also may cause immune cells to multiply, mature, move from one place to another, or stick to certain spots. Interleukin proteins also drive inflammation and immune responses.

Atopic dermatitis is an inflammatory condition in your skin. It's driven mainly by interleukin cytokines. Two that are especially important in atopic dermatitis are IL-4 and IL-13. As a result, doctors consider IL-4 and IL-13 good targets for treating atopic dermatitis. IL inhibitors work by blocking interleukins. 

IL inhibitors are a type of medicine known as a biologic or monoclonal antibody. Biologics are medicines made from living cells. They are most often antibodies and proteins that block specific substances. Today you'll have multiple IL inhibitors to choose from for your child or teen. While they all target interleukins, they have differences, too. For example, dupilumab was the first IL inhibitor approved for children ages 12 and up in 2019. It works by blocking IL-4 and IL-13. Its use was later extended to include all children ages 6 months and up. In contrast, nemolizumab blocks IL-31, which plays an important role in symptoms of atopic dermatitis including itching, inflammation, and rash. It, as well as tralokinumab (Adbry) and lebrikizumab (Ebglyss) are approved for children 12 and up when topical medicines don't work.

Biologics are safer than medicines that would suppress the immune system in a less specific way. Studies have shown they can clear up the skin and reduce itching in many children, but they don't work for everyone. They also can reduce infection, likely by allowing the skin to heal. But they may come with conjunctivitis or eye irritation and other side effects. Your child won't be able to get any live vaccines while they're taking a biologic such as dupilumab. 

Your child will take IL inhibitors or biologics either through their skin as a pen or autoinjector shot. Pain or fear related to getting a shot is the main reason children stop taking a biologic for atopic dermatitis or why they don't start treatment in the first place. Ask your doctor about your options for IL inhibitors, their benefits and risks, and what you can expect if your child or teen decides to take one of them to treat their atopic dermatitis.

What Are Pros and Cons of JAK Inhibitors for Atopic Dermatitis in Children?

JAK inhibitors work in a different way to limit inflammation in atopic dermatitis. Instead of targeting interleukins, they target proteins known as Janus kinases (JAKs). JAKs receive signals from many different interleukins to drive inflammation. The JAK pathway is known to play a role in many immune-driven inflammatory conditions, including atopic dermatitis. 

Some JAK inhibitors are taken by mouth as a pill. But the JAK inhibitor ruxolitinib is a topical treatment that works in the same targeted way for treating mild to moderate atopic dermatitis in children 12 and up. You may want to consider a JAK inhibitor when other treatments including biologics haven't worked or if you'd rather take a pill or topical medicine over a biologic that has to be injected or infused.

Oral JAK inhibitors come with a black box warning for adverse events including:

• Major heart or blood vessel events
• Blood clots
• Cancer
• Serious infection
• Death

It's important to talk to your doctor about any potential risks to your child. But keep in mind that these serious complications weren't seen in any young people. More study is needed to find out how safe it is to take JAK inhibitors long-term.

What to Consider When Choosing Atopic Dermatitis Treatment for Your Child

There's lots to think about when choosing a treatment for your child or teen with atopic dermatitis. What's best for your child and family may be different from what's best for another child with the same condition. Some key things to consider and talk with your doctor about include:

• How much of your child's body is affected
• How intense the inflamed patches are on the skin
• How bothersome the itching or other symptoms are
• The age of your child and approved treatment options
• Your treatment preferences; for instance whether you'd prefer a topical, oral medicine, or biologic
• How well other treatments are working
• Your health insurance coverage
• What your doctor recommends
• Treatment side effects and risks of complications

Atopic dermatitis severity

Some treatments are approved to treat mild to moderate atopic dermatitis, while others may be better choices when the eczema is moderate to more severe. Ask your doctor about how severe your child's atopic dermatitis is and which treatment options are most likely to give the most benefit without unnecessary risks or costs.

How medicines are delivered

Treatment options include pills or topical medicines your child or teen would take or apply daily. Others will involve shots or infusions they'd need less often. The best treatment options for you may depend on your lifestyle and personal preferences. 

Treatment monitoring 

Your treatment may affect how often your child needs to see their doctor for blood tests and other monitoring. Some may require testing and follow -up to make sure your child or teen:

• Doesn't have latent tuberculosis (TB)
• Doesn't have hepatitis
• Has good kidney and liver function
• Has normal lipid levels

Side effects or safety concerns

Some treatment options will have a longer track record for safety than others. The expected side effects or complications risks also will vary. 

Your health insurance plan

When your child has atopic dermatitis, you'll want to make sure your health insurance plan covers your care team and the treatments you'll need. Consider the treatment you're using now and how much you'll pay out of pocket. Talk to your doctor about other options you may wish to consider if current treatments don't work well enough or stop working. Make sure to factor in any tests or other procedures your child's treatment plan may require.

Questions to Ask Your Doctor

To help you get all the information you need to weigh the pros and cons of different treatments for your child's atopic dermatitis, ask your pediatrician, dermatologist, or health insurance company questions such as:

What treatment do you recommend for my child and why?

How likely is it that the treatment you recommend will work?

What are the most common treatment side effects?

What should we do if we're having trouble sticking to our treatment plan?

Should I get a second opinion or see a specialist?

Does my child need allergy testing? How will that influence their treatment?

What are the risks if my child's atopic dermatitis is untreated or if treatments don't work?

What are other steps we can take at home to help with my child's atopic dermatitis?

How much will treatment cost?

Will my child's treatment be covered by our health insurance?