Severity Scoring and First-Line Topical Therapy for Pediatric AD

Lisa Swanson, MD, narrows in on severity assessment tools that are actually practical for a busy pediatrics office, as opposed to the more elaborate scales used in clinical trials. She highlights the Investigator Global Assessment (IGA), an easy-to-apply score ranging from clear to almost clear to mild, moderate, or severe, which she says any pediatrician's office can use to place a patient's current status. She also points to the itch score, a 0-to-10 scale that clinicians can estimate but should also ask patients and caregivers to rate directly.

From there, Swanson lays out her starting approach to mild-to-moderate AD. For infants, she typically begins with hydrocortisone 2.5% in a cream or ointment base applied twice daily to all affected areas until the skin clears. For older children, she may step up to a mid-potency steroid such as triamcinolone 0.1% or mometasone 0.1% applied twice daily to the body, while reserving hydrocortisone 2.5% for the face and skin folds. For families looking to reduce reliance on topical steroids, she describes topical calcineurin inhibitors — pimecrolimus and tacrolimus — as a steroid-free option appropriate for any body area, generic and accessible, though slower acting and occasionally associated with burning or stinging on application.

Swanson closes by reaffirming that topical corticosteroids remain a strong starting point: they are inexpensive and effective, even as clinicians navigate a climate of heightened steroid phobia among families.

In the next episode, "Reassessing Topical Steroid Therapy and Long-Term Safety in AD," Swanson turns to the follow-up visit, explaining exactly what she checks to know whether a treatment plan is working — and the real risks of leaning on topical steroids for too long.