Case Study 3: Inadequately Managed Pediatric Atopic Dermatitis

This case of a 2-year-old with moderate to severe atopic dermatitis (18% BSA) and a history of poor tolerability to crisaborole highlights the need for a tailored approach. Experts emphasize that a negative experience with one PDE4 inhibitor does not preclude trying another, like roflumilast, due to its distinct molecule design and vehicle, which confer superior tolerability and efficacy. Dr. Eichenfield details a systematic evaluation for systemic therapy consideration, focusing on disease burden, sleep disruption, infection history, and quality of life impact. He stresses that high BSA alone doesn't mandate systemics; the decision hinges on chronicity, response to prior topical steroids, and family readiness for a long-term treatment commitment (9-12 months). The consensus is to aim for 90-95% clearance with an aggressive topical regimen first, with close follow-up, reserving systemics for cases with profound, sustained impact.