A 4-year-old has had recurrent pruritic flexural eczema since infancy. His mother has asthma. Examination shows lichenification of antecubital and popliteal fossae, dry skin, and Dennie-Morgan infraorbital folds. He has been on potent topical steroids for 3 months with rebound on stopping. The most appropriate long-term maintenance therapy to reduce relapse frequency is:

• A Continuous moderate-potency topical corticosteroids daily
• B Oral antihistamine regularly for pruritus control
• C Oral prednisolone 1 mg/kg for 3 weeks followed by taper
• D Proactive twice-weekly topical tacrolimus (calcineurin inhibitor) on previously affected skin ✓

Explanation

Proactive (reactive maintenance) therapy with twice-weekly application of topical calcineurin inhibitors (tacrolimus 0.03% for children) on previously affected areas is the evidence-based approach for preventing relapse in moderate-to-severe atopic dermatitis. This strategy significantly reduces flare frequency without the skin atrophy and systemic absorption risks of continuous corticosteroid use. Tacrolimus inhibits T-cell activation without corticosteroid-related adverse effects and is safe for long-term use. Regular oral antihistamines have weak evidence for AD-related pruritus. Continuous potent topical steroids cause atrophy, striae, and adrenal suppression. Systemic steroids produce severe rebound and are not indicated for maintenance.

Reference: Ghai Essential Pediatrics, 10th ed.

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Written and medically reviewed by the StethoPrep medical team.