Atopic dermatitis in children: when topical steroid treatment “does not work”
BMJ 2021; 372 doi: https://doi.org/10.1136/bmj.n297 (Published 18 February 2021) Cite this as: BMJ 2021;372:n297
- Jin Ho Chong, consultant
- Raffles Children’s Centre, Raffles Hospital, Singapore
- Correspondence to JH Chong chong_jinho{at}rafflesmedical.com
What you need to know
If topical corticosteroids for atopic dermatitis do not seem to work, explore how they are being used (quantity, frequency, duration of application), the appropriateness of steroid potency prescribed, the ongoing use of moisturisers, the presence of other skin infections, and potential allergen exposure
Many other conditions mimic atopic dermatitis in children, so the diagnosis warrants frequent review to assess for treatment response, especially if the skin lesions look atypical
Refer patients who do not show clinical improvement or who experience frequent, severe flares while on confirmed, adequate topical therapy—or patients for whom the diagnosis is unclear—to a paediatric dermatologist or paediatrician to consider the use of second line therapy or to explore alternative diagnoses
A 1 year old boy visits your clinic. He received a diagnosis of atopic dermatitis six months ago. On return visit today, his rash and pruritus have worsened despite intermittent application of a small quantity of hydrocortisone 1% cream. His sleep has been constantly interrupted by scratching. On examination, his skin is dry with excoriated, erythematous plaques on his limbs and trunk. His parents want to stop using topical corticosteroids (TCS) out of concern for side effects and because the cream is not working.
Atopic dermatitis, a type of eczema, is the most commonly diagnosed paediatric dermatosis (box 1), affecting about 20% of children.2
Diagnosis of atopic dermatitis
Essential features
Pruritus
Acute: Erythematous papules, scaly patches with oedema and excoriations that are distributed in age related patterns (eg, face, trunk, and extensor surfaces of extremities in infants, flexural surfaces in children)
Chronic: Lichenification, dyspigmentation
Other features
Early age of onset
A personal or family history of atopy
Dry skin1
Emollients are essential treatment for acute flare and for maintenance, and TCS continue to be the first-line drug treatment.23 Sub-optimal management results in poor control of symptoms, which negatively affects quality …
Log in
Log in using your username and password
Log in through your institution
Subscribe from £157 *
Subscribe and get access to all BMJ articles, and much more.
* For online subscription
Access this article for 1 day for:
£30 / $37 / €33 (excludes VAT)
You can download a PDF version for your personal record.