Numerous emollients are available (Box 2), and the choice depends on the severity of the AD (greasier emollients are used for more severe xerosis), the climate (a less greasy product is needed in hot, humid weather) and personal preference. Cost can also be a factor and, as large amounts are required, compliance is more likely if this is minimised. Simple generic preparations, such as emulsifying ointment BP mixed with water, are as effective as proprietary compounds. Generally, greasier emollients available in tubs tend to be better moisturisers than thinner lotion preparations in pump packs. The adverse effects of some emollients can limit their use. The ubiquitous product sorbolene cream can cause stinging in some children that can lead to noncompliance and loss of confidence in treatment. It is helpful to keep samples of various emollients in the office for patients to try before purchase to determine if there is a problem. Useful over-the-counter emollient preparations include, for example, QV cream, Cetaphil moisturising cream, Dermaveen moisturising lotion, and Dermeze, Epaderm and DermaDrate products (the latter brand is useful for severe xerosis, but may sting).
Medical management of dermatitis
Topical corticosteroids, which have been available for many years and for which we have long-term follow up information, remain the treatment of choice for mild to moderate AD. If used correctly, they are very safe and effective. Despite these facts, fear of their use is widespread in the community and is termed corticosteroid phobia. Social media have only added to the distrust of these medications and fear of corticosteroids is as prevalent and troubling now as it was 25 years ago.6 Thus it is important that doctors prescribing them are positive and reassuring about their usefulness. It is important to keep in mind that many other people, including the pharmacist, baby health nurse, naturopath, friends and relatives – all possibly more trusted by the patient than their doctor – may be denouncing them as dangerous.
The main fears with topical corticosteroids are that they will ‘thin the skin’ and ‘depress the immune system’. Both are theoretically true if potent preparations are overused or applied under plastic occlusion. However, when used as recommended below, this is highly unlikely.
Topical corticosteroids should be applied daily to any areas of active dermatitis, titrating the strength of the preparation and the frequency of application to the severity of the dermatitis. An emollient is applied to the entire skin before the corticosteroid is applied. Patients should have a range of topical preparations. If there is an inadequate response to a milder preparation after three days, a stronger one should be used.
Generally, the use of corticosteroids in children does not differ significantly from that in adults; however, the issues discussed in Box 3 are important to consider.
Other topical anti-inflammatory medications
There are two topical calcineurin inhibitors: pimecrolimus, which is available commercially as a 1% cream; and tacrolimus, which is available through compounding chemists as a 0.1% and 0.03% cream or ointment. Of the two preparations, tacrolimus is the more effective. These products are certainly no more effective, are more expensive and are much more likely to be irritating than topical corticosteroids. A recent meta-analysis has not shown that they are superior.7
Pimecrolimus has been evaluated in children and is indicated for the treatment of AD in children over 3 months of age. It is used twice daily. Its main advantage over topical corticosteroids is its lack of atrophogenic properties, particularly in thin skin such as the face in children who are unresponsive to mild corticosteroid preparations or who need to use them continuously.