What We Still Don't Know: Gaps, Phototherapy, and the Future of Pediatric Eczema Care

As the therapeutic arsenal for pediatric atopic dermatitis has expanded, clinicians increasingly face decisions that go beyond which medications are effective—they must weigh real-world practicality, patient age, disease burden, and, inevitably, what the evidence will and will not support. The final section of the recently published pediatric atopic dermatitis guidelines from the Journal of the American Academy of Dermatology (AAD) addresses phototherapy and older systemic agents, and in doing so highlights one of the most consequential limitations in the current evidence base.

Andrew C. Krakowski, MD, of St. Luke's University Health Network, interpreted the guidelines as empowering clinicians to move past phototherapy—logistically burdensome, requiring two to three clinic visits per week and often disrupting school schedules—toward biologic and targeted therapies more directly. Torres-Zegarra, of Children's Hospital Colorado, University of Colorado Anschutz, agreed while noting that phototherapy remains a reasonable option for families with strong reservations about systemic therapy or for patients with extensive body surface area involvement and ready access to a phototherapy unit. Both physicians acknowledged that the guideline's most significant gap is the lack of direct head-to-head comparisons between treatment modalities: without Consumer Reports-style comparative data, neither the clinical superiority nor the cost-effectiveness of one agent over another can be established with confidence. Torres-Zegarra pointed specifically to the unresolved question of whether methotrexate and dupilumab differ meaningfully in laboratory changes requiring intervention—a comparison that remains absent from the literature.

In this concluding segment of the HCPLive special report, Krakowski and Torres-Zegarra reflect on what the guidelines represent for the field: a formal acknowledgment that pediatric atopic dermatitis is a distinct clinical entity worthy of dedicated research, and that the tools now available to treat it can achieve outcomes that would have been difficult to imagine a decade ago. The expectation of near-complete clearance, once rare, is increasingly the norm—and for clinicians who have watched children struggle with this disease throughout their careers, that shift is, as both physicians agreed, a remarkable moment to be practicing pediatric dermatology.

Disclosures: Krakowski and Torres-Zegarra have no relevant reported disclosures.

References

1. American Academy of Dermatology Issues First-Ever Pediatric Atopic Dermatitis Guidelines, Highlighting Prevention Strategies and Effective Treatments. American Academy of Dermatology. April 7, 2026. Accessed June 4, 2026. https://www.aad.org/news/aad-issues-first-pediatric-atopic-dermatitis-guidelines.

2. Smith T. First-Ever Pediatric Eczema Guidelines Issued by American Academy of Dermatology. HCPLive. April 10, 2026. Accessed June 4, 2026. https://www.hcplive.com/view/first-ever-pediatric-eczema-guidelines-issued-american-academy-dermatology.