Divided into two separate manuscripts published together, the American Academy of Dermatology (AAD) has issued guidelines for the treatment of atopic dermatitis (AD) in children, covering therapeutic options in one and reviewing prevention and comorbid conditions in the other.

These are the first pediatric guidelines for AD ever issued by the AAD, and they summarize a growing expansion of treatment options across multiple drug classes, according to Dawn M.R. Davis, MD, a co-chair of the multidisciplinary workgroup that produced each of the publications.

“The number of treatments with labelling for children based on multicenter trials has grown, permitting a larger number of evidence-based recommendations than might have been possible even a few years ago,” said Davis, chair of the Division of Clinical Dermatology at the Mayo Clinic, Rochester, Minnesota.

Published online on April 7, 2026, in the Journal of the American Academy of Dermatology, the management guidelines provide sufficient evidence to confer a “strong” basis for the majority of its 27 recommendations. The remaining recommendations, with low or moderate “certainty of evidence,” are characterized as “conditional.”

No Method of Prevention Is yet Evidence-Based

In the document covering primary prevention and comorbid disease conditions, none of the 14 prevention recommendations were labelled as “strong.” The certainty of evidence was “low” or “very low” in all cases. In a second section evaluating 30 potential comorbid diseases, only eosinophilic esophagitis was supported by a “high” certainty of evidence. The majority of others were of “moderate” certainty, such as an association with food allergies or allergic rhinitis.

All six of the topical anti-inflammatory pharmacologic therapies with an FDA indication for AD are recommended in the new guidelines, but only corticosteroids and calcineurin inhibitors were recommended specifically as options for maintenance therapy (intermittent use). The reason is simple, according to Davis.

“This is where we have the evidence,” she said in an interview with Medscape Medical News. This does not negate the potential for the other agents — tapinarof cream, roflumilast cream, ruxolitinib cream, and crisaborole ointment — to demonstrate efficacy and safety for maintenance, but for the purposes of a guideline, evidence was essential.

Although conditional and based on “very low” certainty of evidence, the guidelines recommend against using antimicrobials topically in the absence of signs of infection in any patient younger than 18 years.

Of the 12 systemic therapies evaluated in the pediatric guidelines, all four of the biologics with an FDA indication for pediatric AD — dupilumab, tralokinumab, lebrikizumab, and nemolizumab — are listed as potential options. The two JAK inhibitors with an FDA indication for pediatric AD — upadacitinib, and abrocitinib — are included along with baricitinib, which is not FDA-approved for AD in children or adults (but, the guidelines note, is approved for treating AD for children aged 2 years or older in Europe).

With the exception of dupilumab, which is indicated for treating AD in children aged 6 months or older, all of these targeted systemic agents are considered appropriate for children aged 12 years or older.

Although FDA-Approved, Systemic Steroids Not Recommended

Of the systemic therapies listed, only corticosteroids were not recommended in the new guidelines despite an FDA indication in children. An exception was made for acute and severe exacerbations when systemic corticosteroids might be offered as a bridge to safer therapies.

The systemic immunosuppressants methotrexate, mycophenolate mofetil, azathioprine, and cyclosporine are also included among options in pediatric AD, but all have been given a “conditional” recommendation that include in some cases, a limit on duration or, in the case of methotrexate, age younger than 2 years.

Except for exclusions like patient age, none of the options on the list of topical or systemic therapies have been ranked as preferred in a stepwise algorithm or in groupings such as first- or second-line. Again, this is based on lack of trial data.

“We just do not have the comparative evidence,” explained Davis, who noted that the pivotal studies of even the most recent agents were compared with placebo, not another active agent. She acknowledged that drugs with different mechanisms might not be interchangeable for efficacy or safety across all patients or those defined by phenotype, but this has yet to be demonstrated.

“With targeted therapies, it seems likely that not all mechanisms will be shown to work equally well in every patient,” Davis explained. “We hope that we might provide some direction for individualized care by the next set of guidelines. There is a great deal of work underway in this area.”

The AAD guidelines are comprehensive and cover such treatment topics as phototherapy and bathing practices, such potential environmental triggers as water softening agents, and a long list of comorbidities ranging from other atopic diseases to cardiovascular risk, bone health, and skin infection.

Prevention of AD Remains Major Unmet Need

Not surprisingly, multiple gaps in knowledge are outlined in both the treatment and the prevention/comorbidity publications. Particular attention was paid to the potential opportunities for prevention. There is not much supportive evidence for any strategy to prevent AD at the current time, but “the ability to reduce the incidence of AD would be very impactful,” and more studies on prevention “will be useful,” the guidelines state.

“Moisturizers do seem to help, but there are almost no studies comparing ingredients, so no specific moisturizers are recommended,” Davis said. She cautioned that there is good evidence that moisturizers do not enhance the effect of topical corticosteroids, so the guidelines specifically recommend that these two should not be used in combination.

The AAD guidelines are the latest in a series of pediatric AD guidelines published in the last several years. These include 2023 guidelines published jointly by the American Academy of Allergy, Asthma, and Immunology and the American College of Allergy, Asthma, and Immunology, the 2025 clinical report from the American Academy of Pediatrics, and the 2025 European guideline (EuroGuiDerm), which also includes adults but provided separate algorithms for those older than 18 years and those younger.

All four of the guidelines are generally compatible, according to Davis, who said that the AAD workgroup reviewed other guidelines before embarking on their own. The differences between these guidelines are defined mostly by perspective rather than by key points of management and drug choice. For one example, the AAP guidelines provide detailed advice about when primary care physicians should refer patients.

The lead author of the AAP guidelines, which were also assembled by a multidisciplinary team, was Jennifer Schoch, MD, professor of dermatology at the University of Florida in Gainesville, Florida. Like Davis, she said the time was ripe for creating treatment guidelines for AD in children.

“Atopic dermatitis in children requires a pediatric-specific approach because treatment decisions are influenced by age, developmental stage, and caregiver burden in ways that differ from adults,” Schoch told Medscape Medical News.

Also, the landscape for treatments with labeling in children has changed markedly over the past several years, Schoch noted.

“Therapies long used by pediatric dermatologists, such as topical calcineurin inhibitors in infancy, have been prescribed off-label because pediatric FDA approvals have trailed clinical experience,” she said. She stressed that several newer targeted therapies “are now firmly part of pediatric eczema care,” while strategies like topical antibiotics should no longer “be used in first-line treatment nor in place of appropriate anti-inflammatory therapy.”

All of the guidelines, including those offered by the AAD, describe the strength of the evidence of each treatment option along with context that might help clinicians select among drug classes. In addition, Davis and Schoch indicated that the guidelines will clarify which preventive measures, treatments, and maintenance are not anchored in evidence and might be best avoided.

The guidelines were funded by internal funds from the AAD. Davis and five guideline authors had no disclosures; the remaining authors had disclosures with multiple companies. In the AAP guideline, Schoch disclosed a financial relationship with Janssen Biotech (advisory board member).