The American Academy of Dermatology (AAD) has released its first pediatric guidelines for atopic dermatitis, offering a structured approach to treating eczema in patients under 18. The new document outlines 27 evidence-based recommendations derived from multidisciplinary expert panels and the GRADE methodology, covering skin care, topical medications, phototherapy, and systemic treatments.
Hydrating agents remain a central recommendation, though the authors do not favor any specific product due to insufficient data. “Of all over-the-counter interventions, hydrating agents have the strongest data,” they write. Topical corticosteroids are recommended for patients under 18, and intermittent maintenance use—at low or medium strength, up to three times a week—is suggested to reduce flare-ups. Topical calcineurin inhibitors like tacrolimus and pimecrolimus are also advised, including for intermittent proactive use.
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Dr. Dawn M. R. Davis, co-chair of the AAD expert group, told Medscape that the release comes as the number of treatments with pediatric indications in the United States, supported by multicenter trials, has increased. The guidelines guide clinicians through a progression from non-pharmacological care to topical drug treatments and systemic options. Beyond standard topical corticosteroids and calcineurin inhibitors, the recommendations address crisaborole, roflumilast, ruxolitinib, tapinarof, monoclonal antibodies, JAK inhibitors, and older immunosuppressants. The document clarifies the strength of available data and the conditions under which each was evaluated rather than ranking them as first- or second-line therapies.
Even with these new options, the authors stop short of providing a strict hierarchy for treatment selection. Dr. Davis explained that they simply do not have the comparative data. Even for the most recent treatments, key trials have generally compared medications to a placebo rather than to another active option.
The guidelines also identify specific practices clinicians should avoid in pediatric patients. The AAD recommends against using topical antimicrobials in the absence of signs of infection. This applies to non-infected atopic dermatitis, though the guidance notes that impetiginization or cellulitis require a different approach.
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Systemic corticosteroids should not be used as maintenance therapy for atopic dermatitis in children. Their use is reserved for severe acute flare-ups and as a short-term transitional treatment to a safer option. Additionally, the AAD recommends avoiding PUVA phototherapy when other modalities are available due to recognized long-term adverse effects, including an increased risk of UV-induced squamous cell carcinoma and photoaging.
While this guidance is valuable for clinicians in North America, it is important to remember that these recommendations are primarily intended for American physicians and specifically aligned with the indications and approvals of the Food and Drug Administration (FDA). For patients in Quebec, the Eczema Society of Canada indicates that there are currently no Canadian guidelines on atopic dermatitis, making this U.S. framework a reference point rather than a direct protocol for local care.
