When and How to Escalate Pediatric Atopic Dermatitis Treatment

For children with moderate-to-severe atopic dermatitis 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.1,2

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.

This segment of the HCPLive 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.

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

References

1. 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.

2. 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.