Systemic therapy of childhood atopic dermatitis

Atopic dermatitis (AD) is a common childhood inflammatory disease that, in a small percentage of cases, can become severe enough to require potent systemic treatment. Many trials have been conducted with systemic agents for the treatment of severe pediatric AD; we review the evidence here. Although corticosteroids are widely used in practice, they are not generally recommended as a systemic treatment option for AD in children. Most patients experience a relatively rapid and robust response to cyclosporine. Treating children with cyclosporine long term is troubling; however, azathioprine, mycophenolate mofetil, and methotrexate are all reasonable alternatives for maintenance therapy in recalcitrant cases. Several additional options are available for the most refractory cases, including interferon-γ, intravenous immunoglobulin, and various biologics. Phototherapy is another modality that can be effective in treating severe AD. Ultimately the choice of agent is individualized. Systemic therapy options are associated with potentially severe adverse effects and require careful monitoring. Nonsystemic approaches toward prevention of flares and long-term control of atopic dermatitis in pediatric patients should be continued in conjunction with systemic therapy. In the future, more targeted systemic treatments hold the potential for effective control of disease with fewer side effects than broadly immunosuppressive agents.