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MOC-prescription-anti-inflammatory-therapies

John Montgomery5 min read

Prescription Anti-Inflammatory Therapies

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  • Topical Corticosteroids — First-line anti-inflammatory creams for eczema flares; mild potency for toddler face/folds, once daily works, weekend use prevents flares.
  • Hydrocortisone — Mild-potency TCS (0.5/1/2.5%); default for toddler face, neck and nappy area. UK OTC only for 10+, US OTC (≤1%) for 2+.
  • Clobetasone Butyrate — Moderate-potency TCS (Eumovate 0.05%); a step up from hydrocortisone. UK OTC pack is 12+ only, so toddlers need a prescription.
  • Clobetasol Propionate — Very potent (UK) / group I (US) topical steroid; specialist-only in children; the hidden steroid most often found in fake ‘herbal’ creams.
  • Fingertip Unit — Cream along an adult fingertip (~0.5 g); age-banded FTU tables (e.g. 1–2 yrs face/neck 1.5 FTU) set toddler steroid doses.
  • Weekend Therapy — Proactive twice-weekly TCS (or TCI) on usual flare sites after control; cuts flares (NNT≈3) with no thinning seen in trials.
  • Stepped Care Approach — NICE CG57 model: emollients always, add treatments by severity (mild/moderate/potent TCS, TCIs, bandages, phototherapy, systemics).
  • Wet Wrap Therapy — Damp cotton layer plus dry layer over emollient or steroid for severe flares; helps in practice but low-quality evidence it beats TCS alone.
  • HPA Axis Suppression — Absorbed steroid dampens cortisol; ~3.8% of children on TCS show reversible lab suppression. Clinically significant cases need misuse.
  • Iatrogenic Cushing Syndrome — Steroid excess from absorbed medicine (moon face, high BP, poor growth); in toddlers nearly only after months of unsupervised strong TCS.
  • Skin Atrophy — Steroid skin thinning; rare in children on guideline TCS (Hong 2011: 0/210 sites), mostly reversible; striae are permanent but rare.
  • Perioral Dermatitis — Rosacea-like papules around a child’s mouth, nose or eyes, often triggered by facial steroids; stop the steroid, use topical antibiotics.
  • Steroid Phobia — Fear of topical steroids in about 20–80% of parents; roughly triples non-adherence and pushes families to ‘natural’ or unlabelled creams.
  • Topical Steroid Withdrawal — Patient-named, poorly defined reaction after stopping prolonged potent steroids; regulators call it rare; only ~21 child cases published.
  • Topical Calcineurin Inhibitors — Steroid-free tacrolimus/pimecrolimus; no skin thinning, suits face/eyelids; US cancer boxed warning vs reassuring 3.4M-patient data.
  • Tacrolimus — Calcineurin-inhibitor ointment (Protopic 0.03%/0.1%); 0.03% licensed from age 2; steroid-free option for face/eyelids.
  • Pimecrolimus — Calcineurin-inhibitor cream (Elidel 1%) for mild-moderate eczema; UK licence from 3 months, US/SA from 2 years.
  • PEER Registry — US pimecrolimus safety registry (from 2004), 7,457 children aged 2–17; cancer rate no higher than expected (SIR 1.2); AD often persists.
  • Crisaborole — Steroid-free PDE4-inhibitor ointment (Eucrisa); US-licensed from 3 months since 2020; EU licence withdrawn 2022; stings in some.
  • Roflumilast Cream — Once-daily steroid-free PDE4 cream (Zoryve); US-licensed 0.05% for ages 2–5 since Oct 2025; not licensed in EU or UK.
  • Tapinarof Cream — Once-daily steroid-free AhR-agonist cream (Vtama); US-licensed for AD from age 2 since Dec 2024; folliculitis common; not licensed in EU/UK.
  • Ruxolitinib Cream — Topical JAK1/2 inhibitor (Opzelura); US from age 2 (Sept 2025) after TRuE-AD3; boxed warning; ≤20% BSA, 60 g/2 wk; EU adults only.
  • JAK Inhibitors — JAK-blocking AD drugs: oral abrocitinib/upadacitinib ≥12 y, EU baricitinib ≥2 y; US ruxolitinib cream ≥2 y (2025); boxed warnings.
  • Dupilumab — IL-4Rα antibody injection licensed from 6 months (US mod-severe, EU severe only); strong preschool RCT; conjunctivitis main side effect.
  • LIBERTY AD PRESCHOOL — Phase 3 RCT of dupilumab in 162 children aged 6 months–5 years with moderate-to-severe AD (Paller, Lancet 2022).
  • Conjunctivitis — Eye-surface inflammation; main specific dupilumab side effect in children (5% in preschool RCT, 19% over 2 years), mostly mild.
  • Systemic Immunosuppressants — Oral ciclosporin/methotrexate for severe childhood AD; TREAT RCT (2–16 y): ciclosporin faster, methotrexate more durable; both off-label.
  • TREAT Trial — UK/Irish RCT (n=103, ages 2–16): ciclosporin vs methotrexate for severe childhood AD; CyA faster, MTX more durable.
  • Phototherapy — Hospital narrowband UVB for severe eczema; child data start at age 4; rarely used in toddlers (practicalities, lifetime cancer concern).
  • Oral Antihistamines — Cochrane 2019: no convincing evidence oral H1 antihistamines help eczema; NICE allows short trials; sedating types risky in toddlers.

Key Relations

Hydrocortisone [part-of] Topical Corticosteroids Clobetasone Butyrate [part-of] Topical Corticosteroids Topical Corticosteroids [relates] Topical Calcineurin Inhibitors Fingertip Unit [defines] Topical Corticosteroids Weekend Therapy [part-of] Topical Corticosteroids Steroid Phobia [opposes] Topical Corticosteroids Topical Steroid Withdrawal [relates] Steroid Phobia Clobetasol Propionate [part-of] Topical Corticosteroids Topical Calcineurin Inhibitors [part-of] Weekend Therapy Wet Wrap Therapy [supports] Topical Corticosteroids HPA Axis Suppression [precedes] Iatrogenic Cushing Syndrome Skin Atrophy [causes] Steroid Phobia Perioral Dermatitis [relates] Topical Steroid Withdrawal Pimecrolimus [treats] Perioral Dermatitis Tacrolimus [part-of] Topical Calcineurin Inhibitors PEER Registry [supports] Pimecrolimus Crisaborole [relates] Topical Calcineurin Inhibitors Roflumilast Cream [relates] Crisaborole Tapinarof Cream [relates] Topical Corticosteroids Ruxolitinib Cream [part-of] JAK Inhibitors JAK Inhibitors [relates] Dupilumab Dupilumab [precedes] JAK Inhibitors LIBERTY AD PRESCHOOL [supports] Dupilumab Systemic Immunosuppressants [relates] Topical Calcineurin Inhibitors TREAT Trial [supports] Systemic Immunosuppressants Phototherapy [relates] Topical Corticosteroids Hydrocortisone [relates] Skin Atrophy Clobetasone Butyrate [relates] Clobetasol Propionate Topical Corticosteroids [causes] Skin Atrophy Fingertip Unit [relates] Hydrocortisone

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