PA24 Evaluating the efficacy and safety of systemic immunomodulatory therapies in paediatric atopic dermatitis: a comprehensive critical review

Abstract Atopic dermatitis (AD) is a prevalent chronic inflammatory skin disorder, primarily affecting children and adolescents, especially in developed countries. It is characterized by intense pruritus that results in disruption of sleep, concentration and daily activities. Persistent scratching results in excoriations and skin infections. The management is directed at symptom control and flare prevention through emollients, topical corticosteroids and systemic therapy when necessary. While the severity of AD varies, only a subset of patients require systemic therapies for adequate symptom management. Our aim was to systematically evaluate the evidence on the use of systemic immunomodulatory agents for the treatment of paediatric AD. A comprehensive search was conducted in PubMed. Inclusion criteria encompassed randomized controlled trials, case–control studies, case series and case reports that met the following criteria: (i) assessment of systemic immunomodulatory treatments, (ii) moderate-to-severe AD unresponsive to potent topical anti-inflammatory therapies and (iii) inclusion of paediatric patients up to 19 years of age. In total 21 studies were included, evaluating seven distinct systemic treatments across 532 paediatric patients with moderate-to-severe AD. Due to the heterogeneity in study design and treatment protocols, a meta-analysis was not feasible. The studies provided critical insights into the efficacy of treatments against AD in children. There were several assessment tools used in the studies, including Scoring Atopic Dermatitis, Eczema Area and Severity Index and Investigator’s Global Assessment, among others. Qualitative analysis revealed that all systemic treatments evaluated led to clinical improvement in paediatric AD, although the degree of efficacy varied. Among the immunosuppressive agents, ciclosporin emerged as the first-line treatment for short-term use, followed by methotrexate. More recent studies also indicate that dupilumab demonstrates promising efficacy and safety in the treatment of childhood AD. The results of various studies provide valuable insights into the effectiveness of treatments for AD in children, but the lack of universally accepted guidelines, as well as variations in scoring systems used between countries, complicates comparisons and clinical recommendations. While systemic therapies for paediatric AD have demonstrated varying degrees of effectiveness, there remains a lack of robust evidence supporting long-term treatment options and head-to-head comparisons of these agents. High-quality trials with rigorous methodologies are needed to provide stronger evidence and facilitate the development of international guidelines for the optimal management of paediatric AD.