Treatment of atopic dermatitis in children - necessary information for parents

Atopic dermatitis (AD) — is a chronic relapsing inflammatory skin disease characterized by redness, dryness, rash, and intense itching. 

According to WHO, atopic dermatitis is present in about 20% of children and 10% of adults worldwide, making it one of the most common chronic skin diseases. 

The disease arises due to the interaction of several factors:

• Family history of the disease (approximately 70% of children with atopic dermatitis have a history of atopy (eczema, allergic rhinitis, or asthma) in one or both parents or older relatives (grandparents). 
• Genetic mutations of the filaggrin protein. Its deficiency leads to a disruption of the epidermal skin barrier, resulting in increased water loss through the skin (making it dry), heightened permeability to bacteria, allergens, and other irritants, as well as changes in lipid composition.
• Dysregulation of the immune system: disruption of the skin barrier, penetration of allergens and bacteria, an explosive immune system response, resulting in pronounced inflammation and itching. 
• Altered skin microbiome — reduced quantity and diversity of beneficial bacteria and often excessive growth of pathogenic ones, leading to an increased risk of developing bacterial, viral, and fungal skin infections. 

And what about food allergies? 

A common belief is that atopic dermatitis arises from the consumption of certain foods by a child, but research data asserts: food allergies are NOT a cause for the development of atopic dermatitis. More often, the reverse process occurs: allergens penetrate the body through dry, damaged skin — resulting in an immune system reaction - the production of antibodies to these allergens - the development of food allergies - the onset of the atopic march (a sequential development of allergic disorders: food allergies, allergic rhinitis, allergic conjunctivitis, and asthma). 

That’s why restoring the skin barrier and timely treatment help reduce the risk of further sensitization.

Thus, if a child does not have clear symptoms of immediate allergy (hives, swelling, difficulty breathing after eating), dietary restrictions are not indicated and may even be harmful!

Manifestations of AD 

The main symptoms of AD are redness, pronounced dryness, skin flaking, and intense itching, which often worsens at night and disrupts the child's sleep.

The appearance and location of the rash change with the child's age: 

In infants and young children (up to 2 years), the rash most commonly appears on the skin of the head, face (especially on the cheeks), torso, and the outer surfaces of the arms and legs. 

In older children, the inflammatory lesions become more localized, with the rash usually located in the bends of the elbows and knees, on the skin of the back of the hands, wrists, feet, neck, around the eyes, and behind the ears. There are multiple scratch marks covered with crusts. 

Treatment of AD 

Atopic dermatitis cannot be “cured once and for all,” but with the right selection and timely treatment, it can be reliably controlled, achieve stable remission, and significantly improve the quality of life for both the child and the family.

Treatment is tailored individually (depending on the clinical stage of the disease, the area of affected skin, age, comorbid conditions, and medications the patient is taking, severity of itching, degree of impairment of quality of life) and should be conducted under the supervision of a physician. 

Daily basic care 

• Clothing should be made of cotton or other soft natural fabrics. It is advisable to avoid wool and coarse synthetic clothing that irritates the skin.
• Washing: use hypoallergenic liquid detergents without fragrances and always select the extra rinse cycle.
• Home climate: ensure cool and humid air in the room (overheating and excessive sweating strongly irritate atopic skin).
• Nails: regularly trim the child's nails to minimize skin damage during scratching.
• Bathing: children with AD can and should be bathed, but certain rules must be followed: 
  • Bathtime should be in warm water (32-37°C) for 5-10 minutes; 
  • Use mild cleansing agents without soap (syndets) with neutral or slightly acidic pH; 
  • After bathing, do not rub the skin with a towel, but gently pat it dry.
• Moisturizing: Follow the 3-minute rule: within 3-5 minutes after bathing, when the skin is still slightly damp, apply an emollient. This helps to retain moisture and improves the effectiveness of care. 

Emollients — are moisturizing agents that restore the skin's protective barrier, reduce dryness, irritation, and itching. Their use is a mandatory part of the treatment of atopic dermatitis, regardless of the severity of the disease. 

During remission, it is recommended to apply emollients at least twice a day over the entire body surface. In cases of pronounced skin dryness or during exacerbations, the application frequency may increase to 3-4 times a day. 

To achieve the desired effect, the product should be used in a sufficient quantity. The approximate needs are: 

• infants and children up to 5 years — 250-500 g of the product per week; 
• older children — 500 g or more per week; 
• teenagers and adults — up to 600-1000 g per week. 

The emollient should be applied gently in the direction of hair growth without vigorously rubbing it into the skin. 

It is important to remember: even in the absence of a rash, the skin of a child with atopic dermatitis requires daily care. Regular use of emollients can reduce the number of exacerbations and the need for anti-inflammatory medications. 

Emollients are the foundation for controlling atopic dermatitis.

Exacerbation management (topical therapy) 

When an exacerbation begins (skin becomes red, itchy, plaques appear), emollients alone are insufficient. 

Topical medications are prescribed exclusively by a doctor (pediatrician, pediatric allergist, or pediatric dermatologist) 

For topical therapy, two classes of medications are used:

• Topical corticosteroids (TCS) - modern hormonal creams and ointments. With proper use, they are completely safe and effectively relieve acute inflammation. 
• Topical calcineurin inhibitors (TCI): Non-hormonal medications that also have significant anti-inflammatory effects and are effective for the treatment and prevention of AD exacerbations. They are indispensable for sensitive areas (face, eyelids, skin folds, genital area). 

Note: at the beginning of treatment, they may cause mild temporary burning. Your doctor will advise on how to prevent this. 

After the acute inflammation subsides, the so-called proactive therapy may be applied - a modern approach that involves not waiting for a new exacerbation, but continuing to use the therapeutic agent (TCS or TCI) after complete skin healing, following a scheme prescribed by the physician, on those areas where rashes most often occur. This approach allows for significantly extending remission periods between exacerbations and better controlling the disease. 

Systemic therapy

May be applied in severe cases (lack of disease control and its negative impact on the child's quality of life, despite careful daily care and use of properly selected topical agents).

What NOT to do? 

• Do not use regular soap (it has an alkaline pH and destroys the lipid layer) to clean your child's skin.
• Do not give the child antihistamines (anti-allergy medications) without a doctor's prescription - they do not treat the skin and do not reduce itching in AD. 
• Do not use herbal infusions for baths (such as chamomile, succession, etc.) — they further dry the skin and may cause contact allergies. 

When to see a doctor? 

• The rash is spreading.
• Signs of infection appear (the skin becomes hot, pustules or yellow crusts develop).
• Your standard care does not yield results within a few days.
• The child has difficulty sleeping due to itching.