Does your child have atopic dermatitis that is not improving with treatment? In this article, I explain why this may happen, some of the most common treatment difficulties and when specialist assessment may be appropriate.
Atopic dermatitis is one of the most common inflammatory skin diseases in childhood, but it can also be particularly challenging for parents and caregivers when adequate control is not achieved. If your child continues to experience flare-ups, itching or skin lesions despite treatment, there may be several possible explanations. Below, I review some of the most common reasons why a child with atopic dermatitis may not be improving and what can be considered in each situation.
1. The treatment plan is not being followed as prescribed
Atopic dermatitis often requires consistent treatment and correct application of the prescribed therapies. One common difficulty is concern about topical corticosteroids, sometimes referred to as topical corticosteroid phobia. Parents may use smaller amounts than prescribed, apply treatment less frequently or stop it too early because of worries about possible side effects. When appropriately prescribed and used for the correct duration and body area, topical corticosteroids are an established treatment for atopic dermatitis. If parents have concerns, it is important to discuss them with the dermatologist rather than modifying treatment independently.
Another frequent issue is uncertainty about how and when different treatments should be used. Some medicines are intended primarily for active flare-ups, while others may form part of a maintenance strategy. Understanding which product should be applied, where, how often and for how long is an important part of effective disease management.
2. The treatment plan may need to be adjusted
Every child is different. Some cases of atopic dermatitis can be controlled with appropriate skin care and topical treatment, whereas others require a broader or more intensive therapeutic approach. If treatment has been followed correctly for an appropriate period but the disease remains inadequately controlled, the strategy may need to be reviewed. Assessment by a dermatologist with expertise in atopic dermatitis can help determine whether the current treatment remains suitable.
It is also important to adapt treatment to the child’s age, the severity of the disease, the areas of the body affected, the impact on sleep and everyday life, and the response to previous treatments. Certain areas, such as the eyelids, face or skin folds, may require different treatment approaches from those used on other parts of the body. Similarly, flare treatment and long-term maintenance therapy may need to be combined in a structured way.
3. There may be unrecognised aggravating factors
Children with atopic dermatitis may occasionally develop secondary skin infections, including bacterial infections, which can worsen inflammation and make the disease more difficult to control. Other factors that may aggravate symptoms include heat and sweating, cold or dry weather, irritating fabrics, harsh soaps or skin-care products, excessive friction, and other sources of skin irritation.
Food allergy may coexist with atopic dermatitis in some children, particularly in younger children with moderate-to-severe disease, but food allergy should not automatically be assumed to be the cause of persistent eczema. Unnecessary dietary restriction can have nutritional consequences and should not be introduced without appropriate medical assessment. Environmental allergies may also coexist with atopic disease, although their role in an individual child’s skin symptoms should be assessed rather than presumed. In some cases, another dermatological condition may be present alongside atopic dermatitis or may resemble a flare-up. Examples include contact dermatitis, scabies or other inflammatory or infectious skin conditions. When the clinical pattern changes unexpectedly or does not respond as anticipated, reconsidering the diagnosis can be important.
4. Daily skin care is not sufficiently consistent
Regular use of emollients is an important part of atopic dermatitis management, including between flare-ups. Atopic skin has an impaired skin barrier and tends to lose moisture more easily. Consistent moisturising can help reduce dryness, support the skin barrier and complement anti-inflammatory treatment. Education is therefore an important part of treatment, both for parents and, when age appropriate, for the child.
A suitable daily routine may include short baths or showers with lukewarm water, gentle cleansers when needed, drying the skin by patting rather than rubbing, regular use of moisturisers or emollients, particularly after bathing, and avoiding products that consistently irritate the child’s skin. Environmental factors such as excessive heat or very dry indoor air may also affect comfort in some children.
5. The child may need specialist assessment
When atopic dermatitis is moderate to severe, significantly affects sleep or quality of life, or remains inadequately controlled despite correctly used treatment, a specialist assessment may be appropriate. Current management of childhood atopic dermatitis includes more therapeutic options than were available in the past, including advanced systemic and targeted treatments for selected patients. If the disease remains active despite appropriately selected approved treatments, clinical research may also be relevant in some cases. At the International Center for Medical Research (ICMR), clinical studies may be available for children with atopic dermatitis, depending on the studies active at a particular time and their eligibility criteria. These studies evaluate investigational treatments that are still being researched and are not necessarily available as part of routine clinical care.
Participation in a clinical trial is voluntary, depends on whether the child meets the study’s eligibility criteria, takes place within a regulated research framework, involves specialist medical supervision and follow-up, and does not guarantee that the investigational treatment will provide clinical benefit. Clinical research should not be regarded as a substitute for approved treatment when an established therapy remains the most appropriate option. For selected patients, however, discussing whether a clinical study may be suitable can form part of a comprehensive review of the available therapeutic options.
What to do if your child’s atopic dermatitis is not improving: conclusions
If your child’s atopic dermatitis is not improving, the first step is to review how the treatment is being used and whether the current treatment plan is appropriate. In many cases, better understanding of the treatment regimen, greater consistency or adjustments to the prescribed therapy can improve disease control. If control remains inadequate despite appropriate treatment, a specialist reassessment or second opinion may be helpful. This allows the diagnosis, disease severity, possible aggravating factors and available treatment options to be reviewed in detail.
Atopic dermatitis can often be brought under substantially better control with a consistent, individualised and evidence-based approach. The objective is not simply to treat individual flare-ups, but to reduce the burden of the disease on the child’s skin, sleep, daily activities and quality of life over time.
I invite you to share this article about what to do when a child’s atopic dermatitis is not improving with anyone who may find it useful.
