Intended for healthcare professionals

Practice Practice Pointer

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
  1. Jin Ho Chong, consultant
  1. Raffles Children’s Centre, Raffles Hospital, Singapore
  1. 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

Box 1

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

RETURN TO TEXT

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 …

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