Topical Steroids for Pediatric Atopic Dermatitis: Optimal Treatment Calls for Pharmacist Outreach
Consider for a moment the agony of parents trying to soothe a six-month-old baby suffering from itchy, dry skin caused by atopic dermatitis. It’s likely as challenging to think about the utter discomfort of the baby. To say that atopic dermatitis severely affects quality of life doesn’t begin to illustrate the reality. This is a family that would greatly benefit from the support of their community pharmacist. From recommending OTC skin care choices to boosting compliance and ensuring the best dose and potency for young patients, your expert guidance is invaluable.
Challenges of Pediatric Atopic Dermatitis
The American Academy of Pediatrics (AAP) describes pediatric atopic dermatitis (AD) as a chronic, relapsing and often intensely pruritic inflammatory disorder of the skin.1 The words “chronic” and “relapsing” take on more significance considering that onset occurs before the age of one in 65 percent of children with AD and before the age of five in a majority of the remaining cases. With a prevalence of at least 10 percent, a lot of kids face a very long road of relapsing, “intensely pruritic” skin problems. Here’s a few other facts to better illustrate their quality of life:
- Getting a good night’s sleep is impossible for about half of these children.
- Children with AD have fewer friends and a higher risk of depression and anxiety.
- Parents spend up to three hours daily caring for their children’s skin.
- Parents also report lack of sleep, feelings of guilt, and financial strain due to medical costs.
As you have the opportunity to interact with these parents and children, make it a point to ask about quality of life concerns. Be prepared with a handout listing any resources in the area, such as support groups and mental health agencies, or suggest they look for online support groups available via the National Eczema Association website.
Allergies vs. Atopic Dermatitis
Atopic dermatitis is often referred to as eczema, but the two aren’t quite interchangeable. Atopic dermatitis is the most common cause of eczema in children; eczema is also a skin reaction caused by a long list of other dermatological conditions, such as allergic dermatitis. Remembering this distinction may help when you encounter parents who are confused about AD and allergies. More than 90 percent of parents believe that a food allergy is the primary cause of their child’s AD, but that’s not accurate. Damage to the skin barrier may increase the risk of sensitization to allergens, but allergies do not cause AD. On the other hand, food allergies predict a poorer prognosis:
- Children with AD are six to eight times more likely to have a food allergy.
- Patients with food allergy often have earlier onset and more severe AD.
- Children with early-onset AD have a higher risk of developing food allergies than those with later onset.
- In other words, children with AD who are younger than five years should be screened for allergies.
Skin-Directed Treatment Plan for Atopic Dermatitis
The experts acknowledge that genetic predisposition, immune dysfunction and irritating environmental agents play a role in AD. They’ve learned that children with AD have fewer ceramide lipids in the stratum corneum and higher levels of T-helper cells and various cytokines, which lead to pruritus and inflammation. But the primary cause of AD is skin barrier dysfunction. Treatment is directed by the condition of each child’s skin, focusing on:
- Skin care to repair and maintain the skin barrier
- Topical anti-inflammatory medications.
- Itch control
- Managing infection-related flares
Skin Care: Along with avoiding any known triggers, skin hydration must be maintained. A daily bath in lukewarm water is allowed if it doesn’t irritate the child’s skin. Otherwise, bathing frequency is limited to avoid flare ups. Frequently rehydrating skin with a moisturizer is essential. Pharmacists can improve compliance by teaching parents how and when to apply moisturizers. You can also help them choose from the overwhelming number of OTC moisturizers. Here are a few general tips:
- Recommend products that are fragrance-free and have the fewest preservatives.
- Moisturizers should be applied at least once every day even when symptoms aren’t present.
- Studies show prescription barrier creams aren’t necessarily more effective than OTC ointments in patients with mild to moderate AD—products that are affordable improve compliance.
- Common triggers to avoid include environmental allergens, harsh soaps, rough or non-breathable clothing, excess sweat, and psychosocial stress.
Topical Steroids for First-Line Treatment
The AAP recommends topical steroids as first-line treatment, but calcineurin inhibitors—tacrolimus ointment and pimecrolimus cream—are approved as second-line therapy for children with moderate to severe AD. Many parents have fears and misconceptions about steroids, which means they sometimes don’t use the treatment after they get home.2 When you fill a prescription, it’s important to explain that topical steroids are safe and effective for treating AD in children, as long as they’re used appropriately. Assure parents that the dose is specific for the child’s age and weight. Show them how to use the product so they’re confident about putting it on their child.
Primary care physicians are advised to limit their prescriptions to low-potency steroids for the face, neck, and skin folds, while moderate-potency meds can be prescribed for the trunk and extremities. This list represents only the three classes with the lowest-potency steroids, along with their delivery bases. Choice of delivery base is another essential consideration to avoid irritating delicate skin:
Class VII – Low Potency:
- Hydrocortisone 0.5 percent and 1 percent ointment and cream (OTC)
- Hydrocortisone 2.5 percent ointment, cream, and lotion
Class VI – Low Potency:
- Alclometasone dipropionate 0.05 percent ointment and cream
- Desonide 0.05 percent ointment, cream, lotion, hydrogel, and foam
- Fluocinolone acetonide 0.01 percent oil
- Flurandrenolide 0.025 percent cream
- Triamcinolone acetonide 0.025 percent cream
Class V – Moderate Potency
- Betamethasone valerate 0.1 percent cream
- Clocortolone pivalate 0.1 percent cream
- Flurandrenolide 0.025 percent ointment
- Flurandrenolide 0.05 percent cream
- Fluocinolone acetonide 0.01 percent cream
- Fluocinolone acetonide 0.25 percent cream
- Hydrocortisone butyrate 0.1 percent ointment, cream, and lotion
- Hydrocortisone probutate 0.1 percent cream
- Hydrocortisone valerate 0.2 percent cream
- Prednicarbate 0.1 percent cream
- Triamcinolone 0.025 percent ointment
Community Pharmacists Offer Invaluable Expertise
Children with atopic dermatitis—and especially their parents—need the support and advice that pharmacists are uniquely qualified to provide. Precise medication dosages and the best choice of skin care products make the difference between a child who can stay active and thrive at school and one who can’t fully engage in or enjoy daily activities. Many parents appreciate encouragement and reassurance regarding the maintenance of a treatment regimen to keep the condition under control—and it only takes a few minutes of your time to offer this.
Pharmaceutica North America provides a variety of medications for children with atopic dermatitis, including prescription Fluocinonide, emollient delivery bases, and bulk active pharmaceutical ingredients. Contact us today so we can help support your pediatric patients and fill your pharmaceutical needs.
- “Atopic Dermatitis: Skin-Directed Management,” December 2014, http://pediatrics.aappublications.org/content/pediatrics/early/2014/11/18/peds.2014-2812.full.pdf ↩
- “Topical Steroid Use and Children: Reasonable Fear or a Phobia? June 2011, http://www.skinsight.com/info/blog/2011/06/15/topical-steroid-use-and-children-reasonable-fear-or-phobia ↩