Andrew C. Krakowski, MD, works for St. Luke's University Health Network.

Andrew C. Krakowski, MD

What We Still Don't Know: Gaps, Phototherapy, and the Future of Pediatric Eczema Care

As the therapeutic arsenal for pediatric atopic dermatitis has expanded, clinicians increasingly face decisions that go beyond which medications are effective—they must weigh real-world practicality, patient age, disease burden, and, inevitably, what the evidence will and will not support. The final section of the recently published pediatric atopic dermatitis guidelines from the Journal of the American Academy of Dermatology (AAD) addresses phototherapy and older systemic agents, and in doing so highlights one of the most consequential limitations in the current evidence base.

Andrew C. Krakowski, MD, of St. Luke's University Health Network, interpreted the guidelines as empowering clinicians to move past phototherapy—logistically burdensome, requiring two to three clinic visits per week and often disrupting school schedules—toward biologic and targeted therapies more directly. Torres-Zegarra, of Children's Hospital Colorado, University of Colorado Anschutz, agreed while noting that phototherapy remains a reasonable option for families with strong reservations about systemic therapy or for patients with extensive body surface area involvement and ready access to a phototherapy unit. Both physicians acknowledged that the guideline's most significant gap is the lack of direct head-to-head comparisons between treatment modalities: without Consumer Reports-style comparative data, neither the clinical superiority nor the cost-effectiveness of one agent over another can be established with confidence. Torres-Zegarra pointed specifically to the unresolved question of whether methotrexate and dupilumab differ meaningfully in laboratory changes requiring intervention—a comparison that remains absent from the literature.

 special report, Krakowski and Torres-Zegarra reflect on what the guidelines represent for the field: a formal acknowledgment that pediatric atopic dermatitis is a distinct clinical entity worthy of dedicated research, and that the tools now available to treat it can achieve outcomes that would have been difficult to imagine a decade ago. The expectation of near-complete clearance, once rare, is increasingly the norm—and for clinicians who have watched children struggle with this disease throughout their careers, that shift is, as both physicians agreed, a remarkable moment to be practicing pediatric dermatology.

Disclosures: Krakowski and Torres-Zegarra have no relevant reported disclosures.

American Academy of Dermatology Issues First-Ever Pediatric Atopic Dermatitis Guidelines, Highlighting Prevention Strategies and Effective Treatments. American Academy of Dermatology. April 7, 2026. Accessed June 4, 2026. 

https://www.aad.org/news/aad-issues-first-pediatric-atopic-dermatitis-guidelines

Smith T. First-Ever Pediatric Eczema Guidelines Issued by American Academy of Dermatology. HCPLive. April 10, 2026. Accessed June 4, 2026. 

https://www.hcplive.com/view/first-ever-pediatric-eczema-guidelines-issued-american-academy-dermatology

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In the final segment, the clinicians evaluate the guideline's nuanced positioning of phototherapy relative to newer systemic agents and highlight a gap.

When and How to Escalate Pediatric Atopic Dermatitis Treatment

 whose disease is not controlled with topical therapies alone, the decision to escalate to systemic treatment represents a significant moment in the clinical relationship—and one that requires careful communication. The pediatric atopic dermatitis guidelines published in the Journal of the American Academy of Dermatology (AAD) offer evidence-based direction on systemic therapy selection, grounding what can be a difficult family conversation in data.

Carla Torres-Zegarra, MD, of Children's Hospital Colorado, University of Colorado Anschutz, described her approach: she frames escalation not as a failure of prior treatment but as a recognition that the disease is more than a rash—it is a systemic inflammatory condition—and that the goal is not only skin clearance but also improved sleep, school performance, and overall family functioning. She highlighted dupilumab, the interleukin-4/13 inhibitor approved for atopic dermatitis in patients as young as 6 months, as her preferred first-line systemic agent, citing its pediatric FDA approval, the absence of required laboratory monitoring, and a sevenfold improvement in disease control compared with alternative treatments identified in the guideline.

Torres-Zegarra noted that when she tells families they should expect to see little to no active eczema at a 3-month follow-up, they are often skeptical—until they return. Andrew C. Krakowski, MD, of St. Luke's University Health Network, underscored this shift in expectations, noting that the guidelines effectively signal that clearance, not just improvement, is now the benchmark.

 special report also addresses the practicality of systemic therapy from the family's perspective. Torres-Zegarra contrasted the burden of a twice-daily topical regimen—difficult to sustain across two households or during school years—with an injection given every 2 or 4 weeks, emphasizing that adherence is inseparable from efficacy. Krakowski and Torres-Zegarra review the safety monitoring requirements for JAK inhibitors and discuss how insurance prior authorization pathways continue to shape initiation patterns, even as the evidence base for earlier systemic intervention strengthens.

Krakowski and Torres-Zegarra discuss how to initiate the conversation about systemic therapy with families and review the guideline's drug hierarchy.

Beyond Steroids: Topical Agents in Pediatric Eczema

 presents with an active flare, the selection of a topical therapy involves more nuance than a simple potency ladder might suggest. The new pediatric-specific guidelines published in the Journal of the American Academy of Dermatology (AAD) provide a detailed framework for topical treatment selection, affirming the continued role of corticosteroids while cataloguing an expanded array of steroid-sparing options that have reshaped the treatment landscape.

Andrew C. Krakowski, MD, of St. Luke's University Health Network, and Carla Torres-Zegarra, MD, of Children's Hospital Colorado, University of Colorado Anschutz, walk through the guideline's treatment recommendations, which include topical calcineurin inhibitors (TCIs), phosphodiesterase-4 inhibitors, and topical Janus kinase (JAK) inhibitors alongside corticosteroids. A notable feature of the guidelines is a recommendation for the proactive use of TCIs between flares to reduce recurrence—a practice Torres-Zegarra acknowledged she had not routinely employed, citing practical concerns about insurance access leading to medication shortages when flares occurred. The discussion also addresses black box warnings: for TCIs, the guideline notes that Canada has removed the lymphoma warning, with similar action potentially forthcoming in Europe; for topical JAK inhibitors, a black box warning tied primarily to systemic JAK data remains in place and must be communicated to families.

 special report, Krakowski and Torres-Zegarra share how they counsel patients about these agents in practice, including strategies for prescribing sufficient quantities to support real-world adherence and for labeling prescription instructions clearly enough to prevent confusion between maintenance and rescue use. Krakowski also highlights a clinically meaningful detail from the guidelines: the relative potency table, which reveals that the same molecule in cream versus ointment formulation can represent an entire class difference in corticosteroid strength—information that may be less familiar to clinicians outside pediatric dermatology.

The experts review the guideline's approach to topicals for active atopic dermatitis, covering the appropriate use of topical corticosteroids and more.

examine how the guideline navigates the tension between GRADE-based evidence thresholds and long-established clinical practices, and why its framing as a set of expert recommendations rather than a standard of care gives clinicians meaningful flexibility.

How to Apply the New Pediatric Eczema Guidelines in Practice

Evidence-based guidelines are only as useful as the framework used to interpret them—and the new pediatric 

 recommendations published in the Journal of the American Academy of Dermatology (AAD) are explicit about what they are and what they are not.

 Rather than establishing a standard of care, the authors characterize the document as a set of expert recommendations informed by the best available evidence, acknowledging that individual clinicians, geographies, and patient populations may require different approaches.

Andrew C. Krakowski, MD, of St. Luke's University Health Network, noted that this framing is relatively unusual in the guideline literature and that he found it clarifying. The GRADE system used to score the evidence base rewards large randomized controlled trials, meaning that practices with decades of real-world support but limited trial data—such as oral antibiotics for superinfected eczema—can appear underrepresented in formal recommendations. Torres-Zegarra, of Children's Hospital Colorado, University of Colorado Anschutz, echoed this point, cautioning clinicians against abandoning effective practices simply because they did not meet the threshold for a strong recommendation.

 special report explores the practical implications of that interpretive tension, including how the guidelines can be used as leverage with payers. Krakowski described using the document as a tool to challenge insurance coverage cutoffs that do not align with the expert consensus, arguing that the written endorsement of a recognized academic body carries weight in prior authorization discussions that individual clinical judgment often does not. The conversation reflects a recurring theme throughout the special report: guidelines are most valuable not as prescriptive rules but as evidence-anchored starting points that empower clinicians to advocate for their patients.

This segment examines how the guideline navigates the tension between GRADE-based evidence thresholds and long-established clinical practices.

Andrew C. Krakowski, MD

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