Pimecrolimus is available on the PBS only with an authority prescription and only for the treatment of facial and periocular AD where there are contraindications to the use of topical corticosteroids. It is significantly more expensive than topical corticosteroids. Compared with topical corticosteroids, its very long-term safety is not as well known, although we have up to 20 years of follow up with calcineurin inhibitors so far. Because of the immunosuppressive properties of these agents, there has been concern that in the long term we may see skin cancer as a result of their use, particularly in sunny climates like Australia. It is wise, therefore, to use a sunscreen on exposed skin being treated. Only time will tell how safe the use of these compounds on young children really is.
Parents of children with AD are sometimes keen to avoid the use of topical corticosteroids by substituting pimecrolimus. Most do not realise that it is an immunosuppressant with its own hazards.
Another new anti-inflammatory product is the topical phosphodiesterase-4 inhibitor crisaborole. It is indicated only for mild to moderate AD, is not PBS listed and is significantly more expensive than topical corticosteroids. Its role in treatment is similar to the calcineurin inhibitors and it may well appeal to parents with exaggerated fears of topical corticosteroids.
Oral immunosuppressive therapy
Most children with AD can be very successfully managed with topical therapy. However, for very severely affected children systemic immunosuppression is required. Any child for whom topical corticosteroids are needed in such large amounts that there could be a genuine chance of side effects is a candidate for such treatment.
Oral corticosteroids are contraindicated because severe rebound is usually experienced on withdrawal, and repeated courses destabilise the dermatitis and can result in erythroderma. This situation is completely different from treating acute exacerbations of asthma.
Oral ciclosporin may be initiated by a dermatologist or clinical immunologist for the treatment of very severe AD in children. Treatment must be very carefully monitored, and this means numerous blood tests and blood pressure readings for the child. This is a huge step for most parents, although certainly it can be sanity-saving in children with severe, life-disrupting AD. It is used when all conservative measures have failed to control the dermatitis and the patient’s quality of life is severely affected.
Other medications that may be used in children include azathioprine and methotrexate, which is particularly useful when there is coexisting psoriasis. Newer systemic biologic agents that will become available in future include the injectable interleukin (IL)-4/IL-13 receptor inhibitor dupilumab and the Janus kinase (JAK) inhibitors, which are oral medications. Both can be highly effective and are relatively low in side effects.
Control of infection
The most common infections seen in children with AD are: