Comparative efficacy of biologics and small molecule drugs in treating pediatric atopic dermatitis in patients aged 2-18 years: A 12-16 week network meta-analysis of randomized controlled trials.

Background: Atopic dermatitis (AD) predominantly manifests before age five, with significant phenotype variations across age groups. Despite increasing systemic treatments for pediatric AD, head-to-head comparisons in network meta-analyses focused on children are scarce.

Methods: Through systematic searches of PubMed, Embase, Web of Science, and Cochrane Library up to March 2024, we identified randomized controlled trials (RCTs) evaluating systemic treatments for moderate-to-severe AD in children aged 2-18 years. From 900 screened articles, 8 RCTs (n = 2636) met inclusion criteria, comparing dupilumab, baricitinib, upadacitinib, and abrocitinib versus placebo with standard care. Primary outcome was Eczema Area and Severity Index (EASI) scores at 12-16 weeks.

Results: Upadacitinib demonstrated highest efficacy at both 30 mg (risk difference [RD] 0.62 [0.53, 0.71]) and 15 mg (RD 0.52 [0.42, 0.62]). Dupilumab (weight-based dosing with corticosteroids; RD 0.43 [0.29, 0.57]), abrocitinib (200 mg; RD 0.40 [0.29, 0.50]; 100 mg; RD 0.30 [0.20, 0.41]), and baricitinib (4 mg; RD 0.21 [0.06, 0.35]) also showed significant efficacy over placebo.

Conclusion: This analysis establishes a hierarchy of effectiveness among systemic therapies for pediatric AD, with upadacitinib showing highest efficacy. However, the predominance of adolescent data emphasizes the need for age-stratified studies in younger children and long-term safety assessments.