Management of Atopic Dermatitis in Children Younger Than Two Years of Age by Community Pediatricians: A Survey and Chart Review

Abstract

To look at patterns in treatment of atopic dermatitis (AD) by primary care providers (PCPs), particularly of children <2 years of age because there are no specific guidelines for this population.A total of 52 PCPs from the Chicago metropolitan area were surveyed between April to October 2018. Medical record review included 71,913 encounters of children <2 years and 50,914 of children 2 to 5 years, with an additional 109 patient encounters from the departments of allergy or dermatology at Lurie Children’s Hospital, between September 1, 2017, and September 18, 2018.This was a mixed-methods study consisting of a retrospective medical record review and survey. PCPs were surveyed by using open-ended and multiple-choice questions about AD management of children <2 years. The survey was analyzed by using quantitative and qualitative methods.A total of 88% (45 of 52) of PCPs surveyed reported that their management of children <2 years differed from that of older children. The frequency of AD diagnosis was similar across the 2 groups, as was the frequency of topical corticosteroids (TCSs) prescription (1.8% vs 1.9% of all encounters; P = .9). A total of 80% of PCPs surveyed reported they think they underprescribe TCSs to the <2 years age group, and 64% agreed they were less likely to prescribe high-potency TCSs for these children. From the chart review, children <2 years of age were less likely to be prescribed higher-potency TCSs than children 2 to 5 years were (0.37% vs 0.66% (P < .01) for medium-potency TCSs and 0.05% vs 0.15% (P < .01) for high-potency TCSs). Children initially treated by a PCP but ultimately referred to a specialist, either in allergy or dermatology, were more likely to be prescribed medium-potency and high-potency TCSs by the specialist provider than by their PCP (15% of PCP visits versus 30% of allergy visits and 57% of dermatology visits; P < .001.)The chart review data reflect the survey results of PCP perceiving their undertreatment of AD in children 0 to 2 years of age because children 2 to 5 years of age were more likely to be treated with higher-potency TCSs.Current AD treatment guidelines are not stratified by age, and some recommended therapies, such as topical calcineurin inhibitors, are not indicated in children <2 years of age. In this study, the authors highlight the need for specific treatment guidelines pertaining to this age group. Additionally, patients referred to either an allergist or dermatologist had significantly higher rates of prescription of medium-potency to high-potency TCSs by the specialist provider than by the PCP. Clear guidelines for PCPs on classifying disease severity, guidance on appropriate TCS use in specific age groups, and when to refer patients with AD to specialists may help optimize treatment at the primary care level.