002 Atopic Dermatitis

Indian Academy of
Pediatrics (IAP)
STANDA
RD
TREATME
GUIDELINES
2022
NT
Atopi
Under the Auspices
of the IAP Action
c
Plan 2022
Remesh Kumar R
IAP President 2022
Dermatit
Upendra
Kinjawadekar
is
IAP President-Elect 2022
Piyush Gupta
IAP President 2021
L
Vineet Saxena ead
IAP HSG 2022–2023
Author
V
© Indian Academy of
Pediatrics
IAP Standard Treatment Guidelines

Committee
Chairperson
Remesh
Kumar R IAP
Coordinator
Vineet
Saxena
National
Coordinators
SS Kamath,
Vinod H
Ratageri
Member
Secretaries
13
Atopic Dermatitis
(AD)
Definitio
Atopic dermatitis, is an inflammatory, chronically relapsing, non-contagious,

and extremely pruritic skin disease. (WAO)AD affects roughly 20% of the
paediatric population.
n
Major features Minor features
of AD
Clinical features
Must have 3 or more Must have 3 or more following minor features
features
Pruritus Early age of onset, xerosis, palmar hyperlinearity,
ichthyosis, keratosis pilaris
Characteristic Immediate skin test reactivity, elevated serum IgE,
morphology and cutaneous infection, including Staphylococcus
distribution aureus and Herpes simplex virus
Chronic or relapsing Nipple eczema, cheilitis, pityriasis alba,
course white dermatographism, delayed
blanching, perifollicular accentuation,
anterior subcapsular cataracts
Personal or family Itch when sweating, non-specific hand or foot
history of atopy, dermatitis, Recurrent conjunctivitis, Dennie-
including asthma, Morgan folds, keratoconus, facial erythema or
allergic rhinitis, atopic pallor
dermatitis
Atopic Dermatitis
(AD)
A. Area follow rule of 9.

Scoring for
B. Intensity: Redness, swelling, oozing/crusting, scratch marks, lichenification,

Dermatitis
dryness.
(Scorad)
C. Subjective symptoms: Itch and sleeplessness- each scored by the patient or relative
Atopic
using a visual analogue scale where 0 is no itch or sleeplessness and 10 is

worst imaginable itch or sleeplessness. These scores are added to give
“C” (maximum 20).
Total score (SCORAD) for any individual is A/5 + 7B/2 + C.
If SCORAD is > 50, it indicates severe disease and if SCORAD is < 25, it
indicates mild disease. (European Task Force on Atopic Dermatitis in 1993)
A Cleansing and Bathing

 Regular once-daily bathing with warm (27–30°C) water of short duration
(5–10 minutes)
 Limited use of non-soap cleansers that are neural to low pH,
hypoallergenic and fragrancefree (Syndets)
Measures
1. Non-pharmacological
 Bleach baths: In 0.005% Sodium Hypochlorite can be used for
prevention of bacterial colonisation in moderate to severe cases of AD.
B
Moisturizers/Emollients
 Prompt, frequent and liberal use of preservative-free and fragrance-free
moisturizers.
Treatment
 Soak and seal: Soak the skin in warm water for 15 minutes, light pat
dry and seal in moisturizer for best results. Use atleast 2–3 times a
C day. Can use “wet wrap therapy” in case of severe flare-ups.
Clothing
Smooth clothing, which is light weight, loose and comfortable,
D like cotton, is recommended. Wool and synthetic clothing should
be avoided.
Allergen/Trigger Avoidance
(As they increase the skin barrier dysfunction)
 Aeroallergens like pollens and house dust mites should be avoided in
allergen sensitive individuals (proven on skin testing). Rooms should
be well ventilated with good sunlight, have comfortable temperature,
should be clutter free and with minimal upholstery. Should avoid dry
E dusting and encourage wet mopping.
 Tobacco smoke avoidance, traffic exhaust and volatile organic compounds
exposure reduction (avoid burning wood/ essence sticks/ mosquito
4 repellents) is recommended.
Dietary Intervention
Dietary restriction is recommended in only those individuals with a known
food allergy for specific food items.
Atopic Dermatitis
(AD)
2. Pharmacological Measures:
A Topical Corticosteroids (TCS)

 For acute flare-ups (reactive therapy): Twice daily application till active
lesions subsides. To review after 2 weeks. If lesions have come under control
in 2 weeks, step down the strength of steroids.1
 For maintenance (proactive therapy): Twice weekly application to prevent
relapses. (can be used upto16 weeks) with liberal use of emollients. To be
applied in well hydrated skin. Lowest potency steroid should be used, suitable
for that age.
B Topical Calcineurin Inhibitors (TCI)
Pimecrolimus 1% cream2 and Tacrolimus3 0.03% and 0.1% ointments are
(Topical)
effective in both flareups and maintenance.
Measures
3. Other
 Phototherapy: In resistant cases.
 Antibiotics: Whenever there is skin infection.
 Oral Glucocorticoids: Short course of low dose steroids, 0.5
mg/kg/day upto 1 week can be used for acute flare-ups.
5
Atopic Dermatitis
(AD)
 Immunosuppressive drugs: (For refractory cases) Cyclosporine A, Azathioprine,

Methotrexate, Mycophenolate Mofetil can be used.
Modalities
 Biologicals like dupilumab.

 Phosphodiesterase-4 inhibitors like crisaborole4 and apremilast.
Newer
 Janus Kinase inhibitor (JAK1) like Abrocitinib5 can be used in resistant cases.
 Allergen specific immunotherapy: In select patients only, of positive
sensitization (mostly with house dust mites).
Stepwise management of atopic

dermatitis
Step 1: Step 2: Mild Step 3: Step 4: Step 5:

Dryski AD
(SCORAD Moderate
AD (SCORAD 25- Severead
(SCORAD Uncon-
trolled
n <25) 50) >50) AD
 Avoidance  Weak topical  Proactive Immunosuppres- Biologicals:
of triggers steroids / therapy: Topical sants: Dupilumab
 Emollients, topical CNIs Tacrolimus/ Class Cyclosporin A, in
 Emollient II or III topical M ethotrexate, >12 years
M oisturize s, Glucocorticostero Azathioprine, age
rs antiseptic ids M yco-
s  Wet
(AD: atopic dermatitis; SCORAD: scoring for wraps,
atopic UV phenolate
dermatitis) therapy mofetil
1. Peserico A, Stadtler G, Sebastian M, Fernandez RS, Vick K, Bieber T. Reduction of

relapses of atopic dermatitis with methylprednisolone aceponate cream twice weekly
in addition to maintenance treatment with emollient: a multicentre, randomized,
double-blind, controlled study. Br J Dermatol 2008;158: 801–807.
ces
Referen
2. Meurer M, Eichenfield LF, Ho V, Potter PC, Werfel T, Hultsch T. Addition of pimecrolimus
cream 1% to a topical corticosteroid treatment regimen in paediatric patients with
severe atopic dermatitis: a randomized, double-blind trial. J Dermatolog Treat 2010;
21:157–166.
3. Reitamo S, Rustin M, Harper J et al. A 4-year follow-up study of atopicdermatitis therapy
with 0.1% tacrolimus ointment in children and adultpatients. Br J Dermatol 2008; 159:
942–951.
4. Paller AS, Tom WL, Lebwohl MG et al. Efficacy and safety of crisaboroleointment, a
novel, nonsteroidal phosphodiesterase 4 (PDE4) inhibitorfor the topical treatment of
atopic dermatitis (AD) in children andadults. J Am Acad Dermatol 2016; 75: 494–503
e4.
5. JAMA Dermatol. 2021;157(10):1165-1173. doi:10.1001/jamadermatol.2021.2830.
6

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Indian Academy of

IAP Standard Treatment Guidelines

Atopic dermatitis, is an inflammatory, chronically relapsing, non-contagious,

Major features Minor features

A. Area follow rule of 9.

B. Intensity: Redness, swelling, oozing/crusting, scratch marks, lichenification,

using a visual analogue scale where 0 is no itch or sleeplessness and 10 is

A Cleansing and Bathing

A Topical Corticosteroids (TCS)

effective in both flareups and maintenance.

 Immunosuppressive drugs: (For refractory cases) Cyclosporine A, Azathioprine,

 Biologicals like dupilumab.

Stepwise management of atopic

Step 1: Step 2: Mild Step 3: Step 4: Step 5:

1. Peserico A, Stadtler G, Sebastian M, Fernandez RS, Vick K, Bieber T. Reduction of

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