Steroid-Sparing Solutions Gain Ground in Pediatric AD

“These medications are steroid sparing and potentially very efficacious.... Your patients deserve to use them,” Jeff Yu, MD, MS, chair and associate professor of dermatology at Virginia Commonwealth University School of Medicine in Richmond, said in the latest Dermatology Times DermView discussion. The conversation, titled “Emerging Topical Therapeutics for Pediatric Patients With Atopic Dermatitis,” brought together 2 leading voices in pediatric dermatology: Yu and Peter Lio, MD, clinical assistant professor of dermatology at Northwestern University Feinberg School of Medicine in Chicago, Illinois.

Understanding Pediatric AD Across Ages

Yu opened the discussion by emphasizing that “pediatric atopic dermatitis [AD] can look very different depending on your age and where you are in your life cycle.” He explained that infants often present with lesions on the cheeks and extensor surfaces of the arms and legs—patterns linked to delayed skin maturation and a higher pH in those regions. As children grow, the disease tends to migrate to flexural areas such as the elbows, knees, and neck.

Lio noted that despite the common and mistaken reassurance that children may “grow out” of AD, evidence suggests otherwise. Yu agreed with this notion. “Most kids do not grow out of it. I think it probably just goes into hiding, and then at some point during adulthood, something triggers it for it to pop up—occupation, stress, illness—but I do think it’s always lurking there in the back corner,” Yu commented.

The Evolving Topical Landscape

Lio observed that “if you’re going to treat AD, now’s the time to do it,” reflecting on the surge of innovation in topical and systemic therapies over the past decade. Although topical corticosteroids remain the cornerstone of treatment due to accessibility and reliability, new nonsteroidal options are increasingly used for proactive maintenance.

Yu and Lio walked viewers through the 3 major newcomers—ruxolitinib (Opzelura; Incyte), roflumilast (Zoryve; Arcutis), and tapinarof (Vtama; Organon)—each representing a unique mechanism of action. Ruxolitinib, a topical JAK1/2 inhibitor, is the only JAK inhibitor currently FDA approved for both AD and vitiligo. Roflumilast, a next-generation PDE4 inhibitor, boosts intracellular cyclic AMP to reduce inflammation. Yu highlighted its tolerability: The cream “does not sting and does not burn like the older-generation PDE4 inhibitors,” a crucial factor for adherence in young patients. Tapinarof, an aryl hydrocarbon receptor agonist, decreases oxidative stress and improves skin barrier function through a novel mechanism also effective in psoriasis.

From Management to Maintenance

The conversation turned to strategy, discussing how to integrate these new agents alongside steroids. Yu’s approach is pragmatic: “I go for both from the get-go,” he said, explaining that he provides patients with both a short steroid course for flares and a nonsteroidal topical for maintenance. “Hopefully, the next time you see this topical steroid is months from now.”

This hybrid model reflects an important shift toward proactive AD management, aiming to prevent relapses rather than chase flares. Both physicians emphasized that minimizing cumulative steroid exposure from an early age is increasingly recognized as vital to long-term health.

Efficacy and Safety

Clinical data continue to validate these new topicals as serious contenders. In the TRuE-AD3 trial (NCT04921969), ruxolitinib cream produced near-complete clearance in over half of pediatric patients at week 8, with minimal systemic absorption. “Topical medications have very, very low systemic absorption, certainly not high enough to cause any worrisome systemic adverse effects,” Yu reassured.

Tapinarof, evaluated in the ADORING 1 (NCT05014568) and ADORING 2 (NCT05032859) trials, achieved Investigator Global Assessment improvement in nearly 45% of patients and Eczema Area and Severity Index score reduction of 75% or more in approximately 60% of patients, approaching results once reserved for systemic biologics.

Roflumilast’s Integument-PED (NCT04845620) study reinforced its pediatric suitability: After 4 weeks, 25% of treated children achieved clear or almost clear skin vs 11% on vehicle, and after 1 year of open-label extension, that rate climbed to 73%.

Patient-Centered Factors

Vehicle formulation and cosmetic acceptability can determine a therapy’s success. “Most of these newer topicals only come in a cream formulation,” Yu noted, explaining that patients with darker skin often prefer ointments or oils to avoid visible residue.

Lio added that modern formulation science is challenging old assumptions that ointments are inherently superior, citing advances in emollient technology that improve tolerability without compromising potency. Both agreed that real-world feedback is essential to understanding which products work best for specific patients.

When to Escalate and When to Step Back

Determining when to move from topical to systemic therapy requires careful clinical and patient-reported assessment. Yu encourages open dialogue; Patient perception, he stressed, often reveals more than a single office visit snapshot.

Lio echoed this sentiment: “The only thing that matters is the patient-reported outcomes.” He also reminded colleagues that escalation doesn’t mean abandonment of topicals, which remain essential tools for maintenance and relapse prevention, even alongside biologics.

Conclusion

As the discussion closed, both experts urged clinicians to embrace these modern therapies confidently. “Expand your scope,” Yu advised. “Try it out, give it a fair shot.... I think you’ll be pleasantly surprised at how well some of these work.”

The DermView featuring Lio and Yu paints a hopeful picture for children with AD and their families. From once-daily, steroid-sparing creams to improved vehicles and safety profiles, the modern topical armamentarium enables more personalized, durable, and tolerable management of pediatric AD.