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Evidence-Based Recommendations for Managing Atopic Dermatitis in Pediatric Patients: A Systematic Review and
Rahul Mahajan1, Rashmi Sarkar2, Maitreyee Panda3
1Department of Dermatology, Venereology, and Leprology, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
Insights
Topical steroids and calcineurin inhibitors are effective for mild to moderate pediatric atopic dermatitis (AD). For severe AD, systemic therapies like dupilumab and JAK inhibitors show promise but face access barriers, making cyclosporine a continued option.
Area of Science:
- Dermatology
- Pediatrics
- Pharmacology
Background:
- Atopic dermatitis (AD) is a prevalent inflammatory skin condition in children, affecting 15%-20% globally.
- Current treatments for moderate-to-severe AD include topical medications, phototherapy, and systemic immunosuppressants.
- A significant gap exists in head-to-head comparisons of topical and systemic therapies for pediatric moderate-to-severe AD.
Purpose of the Study:
- To systematically review and compare the efficacy and safety of topical and systemic treatments for moderate-to-severe atopic dermatitis (AD) in pediatric patients.
- To provide evidence-based guidance for selecting appropriate therapies for pediatric AD.
- To identify treatment options considering varying accessibility and cost.
Main Methods:
- A systematic review was conducted following PRISMA guidelines.
- Searches were performed in PubMed and Google Scholar databases from 1975 to 2023.
- Eligibility criteria were applied to identify relevant clinical trials, including randomized controlled trials.
Main Results:
- Out of 1114 initially identified articles, 68 met the inclusion criteria.
- Thirty-four articles focused on topical therapies (corticosteroids, calcineurin inhibitors, emollients), and 34 on systemic therapies (cyclosporine, dupilumab, JAK inhibitors, etc.).
- Forty-one of the included studies were randomized controlled trials.
Conclusions:
- Topical corticosteroids and calcineurin inhibitors are effective and safe for mild to moderate pediatric AD.
- Systemic agents like dupilumab and JAK inhibitors offer rapid symptom reduction but have cost and availability limitations.
- In resource-limited settings, cyclosporine remains a recommended first-line therapy for severe pediatric AD, with oral prednisolone as a short-term option.
Background:
Atopic dermatitis (AD) is the most common inflammatory skin disease in the pediatric age group, affecting 15%-20% of children globally. Initial treatment modes include hydration, occlusive topical medicines, antimicrobial treatment, phototherapy, and systemic immune suppressants in the case of severe to moderate refractory AD. However, there is a lack of head-to-head studies on the choice of topical and systemic therapies for moderate to severe AD in the pediatric age group.
Objective:
This systematic review aimed to determine the efficacy and safety of topical and systemic treatments for moderate-to-severe AD in the pediatric age group.
Method:
A systematic review was performed following the Preferred Reporting Items for Systemic Reviews and Meta-Analyses (PRISMA) guidelines. A search of articles was done from PubMed and Google Scholar from 1975 to 2023.
Results:
We found a total of 1114 possible clinical trials. Of these, 68 articles fulfilled the eligibility criteria. Thirty-four articles discussed topical therapies, which included corticosteroids, calcineurin inhibitors, and emollients, and 34 articles were about systemic therapies, consisting of cyclosporine, dupilumab, upadacitinib, thymopentin, omalizumab, antihistamines, probiotics, and others. Out of 68 studies, 41 were randomized controlled trials.
Conclusion:
Based on the study results, we conclude that topical steroids and calcineurin inhibitors are effective and safe in mild to moderate pediatric AD. It was also demonstrated that while systemic monotherapy with dupilumab (in age groups younger than 6 months) and JAK inhibitors (like abrocitinib and upadacitinib in those younger than 12 years) is highly effective in rapidly reducing severity scores, their high cost and limited availability restrict their use in countries like India. In such settings, cyclosporine (and sometimes oral prednisolone in tapering doses over 2 weeks) is still recommended as a first-line therapy in severe AD while planning for steroid-sparing agents.
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