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A multifactorial disease, atopic dermatitis (AD) is the most common pediatric skin disorder, often occurring in infancy.

"The biology of eczema is different across the ages, whether you look at a 6-month-old or a 2-year-old or a 25-year-old," said Vikash Oza, MD, of NYU Langone Health in New York City. "These patients look different clinically, at the bedside, and immunologically. There are probably differences in the microbiome as well."

For physicians, the management of AD in infants poses unique clinical challenges, including overcoming steroid phobia in parents and caregivers.

"There's nothing wrong with topical steroids, but there's a lot of phobia that limits their use and reduces adherence," said Amy Paller, MD, of Northwestern University Feinberg School of Medicine in Chicago.

She said she routinely raises the issue, even when caregivers don't. "What parent doesn't have some worries about their child using steroids on a chronic basis?" she noted.

Jonathan Silverberg, MD, PhD, MPH, of George Washington University School of Medicine and Health Sciences in Washington, D.C., pointed out that "the caregivers of children with atopic dermatitis tend to be particularly cautious about treatment, and rightly so. The youngest patients are often more vulnerable to adverse events, since there is greater absorption through the skin than in adults."

When used appropriately, however, topical corticosteroids have a relatively long track record of being safe and effective for the treatment of AD. Notably, these agents remain first-line for infants, even as novel systemic drugs continue to flood the therapeutic space for patients ages 6 years and older.

"I don't believe the treatment of infants with systemic therapy is common in clinical practice and it probably shouldn't be," Oza said. "We don't have all the answers, but we are able to help a significant percentage of children with counseling, the aggressive use of medications we already have at our disposal, and close follow-up."

In a on the changing landscape of systemic therapy for pediatric AD, Mary Kate Lockhart, MD, and Elaine Siegfried, MD, both of St. Louis University School of Medicine, noted that ongoing trials of the biologic dupilumab (Dupixent) include children and infants as young as age 6 months.

"Most clinical trials for moderate-severe AD have not included children younger than 12 years to date," they wrote. "However, the pipeline is robust, so the treatment paradigm for AD is sure to evolve."

In the meantime, studies have indicated that early, aggressive treatment may reduce the risk of other atopic morbidities, including immunoglobulin E-mediated food allergies, asthma, allergic rhinitis, allergic conjunctivitis, and eosinophilic gastrointestinal disease.

An of 17-year follow-up data from 285 high-risk infants in the Childhood Origins of Asthma birth cohort showed that those with persistent AD had about four times the risk of developing a food allergy compared with infants with transient disease (21% vs 5.3%, respectively). "These data suggest that immunologic changes in AD, which occur early in life, influence food allergy risk throughout childhood," the investigators wrote.

Early, aggressive treatment of infant AD is also crucial for managing symptoms such as persistent itch, which is a cause of significant in up to 80% of children. Long-term studies have established that frequent sleep disruption during early childhood is associated with an increased risk of stunted growth and development, behavioral and learning disabilities such as ADHD, and anxiety and depression.

"The highest-yield interventions for sleep disturbance are those that achieve better control of the underlying signs and symptoms of atopic dermatitis," confirmed Silverberg.

Long gone are the days when parents of infants with AD could be told to wait it out, use moisturizers, and do their best. With 40% of his AD patients younger than 2, Oza said he talks to every family at every visit about what it means not to treat, and offers clinical evidence on the safety of topical corticosteroids.

"As someone who prescribes more topical corticosteroids for young infants than anyone else in my healthcare system, I can say that the frequency of actually seeing a steroid side effect in an infant is very low," Oza noted. "I would have a hard time recalling skin thinning, stretch marks, or lightening of the skin associated with topical steroid use in an infant."

In babies with moderate to severe disease, Oza said he frequently uses a medium-strength topical steroid for 2 to 4 weeks, then gradually decreases the frequency over a 1-month period. "You want to choose the strength that gets your patient to clear or almost clear within 2 weeks," he stressed.

To maintain disease control and prevent flares, Oza said he often uses off-label pimecrolimus, which is currently approved for use in children ages 2 and older. "We have good safety data for infant use," he explained. In infants with moderate disease, frequent follow-up is critical to reinforce parent education and compliance, and should begin at the 4-week follow-up visit, he emphasized.

Silverberg said the routine use of a written treatment plan is essential to both adherence and long-term management. It should be developed at the initial visit to address the use of multiple topical therapies, and to help parents understand the difference between flare prevention and the treatment of flares.

"The analogy I give every family is that baby eczema is like a story book," said Oza. "There are chapters. The first chapter is intense, frequent use of medications. The second chapter is about starting to back off medications. And in the third chapter, I tell parents that they will be more reliant on good skin care and the occasional use of medicine. It's a road map that helps them understand that eczema just doesn't go away in 1 to 2 months."

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