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Management of atopic dermatitis in children in 2025

Presented by
Dr Marlies de Graaf, University Medical Center Utrecht, the Netherlands)
Conference
DDD 2025
Doi
https://doi.org/10.55788/c06fc124
Atopic dermatitis in children is a complex condition requiring more than symptom control. Recent advances in systemic treatments, including biologics and JAK inhibitors, support a more personalised, early-intervention approach to improve long-term outcomes and overall quality-of-life.

“The disease burden of atopic dermatitis is multidimensional,” said Dr Marlies de Graaf (University Medical Center Utrecht, the Netherlands), discussing the management of atopic dermatitis in children [1]. “Beyond the burden of eczema lesions and symptoms, the condition affects these children’s school performance, mental health, sleep, family dynamics, and social life.” In addition, skin infections and other comorbidities are common in this population. The disease burden is also cumulative, starting with the symptoms of atopic dermatitis and progressively impacting other life aspects over time. So, where do we stand in 2025 in terms of treatment options?

Classic systemic treatment options for children with atopic dermatitis include methotrexate, cyclosporin, azathioprine, mycophenolate mofetil, and oral corticosteroids. Recently, biological therapies and JAK inhibitors have been added to the systemic treatment armamentarium of dermatologists who manage children with atopic dermatitis. Currently available biologics are dupilumab (≥6 months of age), tralokinumab (≥12 years), and lebrikizumab (≥12 years). The approved JAK inhibitors for this indication are upadacitinib (≥12 years), baricitinib (≥2 years), and abrocitinib (≥12 years).

“How do you decide whether a child with atopic dermatitis requires advanced therapy?” asked Dr de Graaf. According to current guidelines, systemic therapy should be initiated when the disease remains uncontrolled despite optimal topical therapy. Therefore, before prescribing systemic therapy, dermatologists should ensure that adherence to topical therapy has been adequate. Another reason for prescribing systemic therapy is the inability to taper topical therapy to a maintenance dose. Furthermore, in cases of uncontrolled disease, dermatologists must carefully confirm or reassess the diagnosis. Conditions such as genodermatosis, scabies, rare immune disorders, and allergic eczema may mimic the signs and symptoms of atopic dermatitis in children. Dr de Graaf also emphasised that children with atopic dermatitis should have access to psychological care, educational support, and appropriate treatment for comorbidities and side effects.

Once a patient becomes eligible for systemic therapy, the next challenge lies in selecting the most appropriate treatment. Dr de Graaf mentioned that this decision is based on clinical experience, evidence-based data, treatment costs, hospital agreements, and the goals of the patient and their parents or caregivers. Available biologics are administered as subcutaneous injections and are generally associated with fewer severe side effects than JAK inhibitors. The most common adverse event seen with biologics in atopic dermatitis is conjunctivitis. In contrast, JAK inhibitors are administered orally and carry a higher risk of infections and acne, although they offer a quicker onset of action than biologics. “The increased risk of acne is often an important concern for adolescents,” noted Dr de Graaf.

Among biologics, dupilumab is the most extensively studied and the only one approved for children younger than 12 years. Moreover, it is also approved for children with asthma (≥6 years) or eosinophilic oesophagitis (≥1 year), making it a practical option for patients with multiple atopic conditions. On the other hand, treatment with tralokinumab may be associated with a lower incidence of conjunctivitis compared with dupilumab. Dr de Graaf also suggested that switching between biological therapies may benefit certain patients.

Within the group of JAK inhibitors, baricitinib is the only approved agent for children <12 years of age. Nevertheless, real-world evidence for baricitinib and abrocitinib in children with atopic dermatitis remains limited. “In studies among adults, baricitinib appears to be slightly less effective than upadacitinib and abrocitinib,” according to Dr de Graaf. Therefore, she argued that upadacitinib and abrocitinib may be the preferred agents in children with severe atopic dermatitis, whereas baricitinib might be more suitable for those with moderate disease. However, more research is needed to validate these observations.

Hereafter, Dr de Graaf stressed that optimising patient-centred care can significantly improve therapy adherence. For most children with atopic dermatitis, the key therapeutic goals include the reduction of itch and the absence and prevention of eczema lesions. In younger children, additional goals also focus on promoting social participation and achieving psychosocial well-being, whereas adolescents typically prioritise being able to function well at school or work.

Dr de Graaf also addressed a frequently raised concern: the safety of vaccine administration in children receiving systemic therapy. The inactivated vaccines, comprising all vaccines in the Dutch vaccine programme except for the MMR vaccine, are safe for children on biologics, and the immune response is most likely unaffected. These vaccines are also safe in patients treated with JAK inhibitors, although the effect on the immune response remains uncertain. According to the current guidelines, live attenuated vaccines, such as the MMR vaccine, should, if possible, be administered at least 4 weeks before initiating treatment with biologics or JAK inhibitors. If the treatment has already been started, it should be temporarily discontinued to allow the vaccine to be administered after a washout period. Treatment can be safely restarted 4 weeks later. Notably, Dr de Graaf highlighted encouraging data suggesting that dupilumab does not impair the immune response to live attenuated vaccines, allowing treatment to continue safely during vaccination. “It is wise to check the patient’s vaccination status and travel plans before starting systemic treatment. The MMR booster vaccine may be administered earlier than the vaccine programme dictates if it benefits the patient,” she added. In unvaccinated patients, treatment with biologics is preferred over JAK inhibitors.

Finally, young patients with severe atopic dermatitis have an increased risk of asthma, food allergies, and allergic rhinitis. Treatment with dupilumab seems to mitigate this risk. Also, patients with concomitant asthma had improved lung function and reduced bronchial inflammation under dupilumab therapy. Similarly, those with concomitant allergic rhinitis have benefited strongly from treatment with dupilumab.

Looking ahead, Dr de Graaf expressed her interest in the potential for disease modification. “It is important to investigate whether disease modification can be achieved if we treat patients early on with these advanced systemic therapies,” she said. Finally, growing interest surrounds the potential of current biologics, JAK inhibitors, and other emerging therapies, such as the OX40 inhibitors.

  1. De Graaf M. Treatment of atopic dermatitis in children in daily clinical practice. Dermatologendagen 2025, 10–11 April, Apeldoorn, the Netherlands.

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