What is the first line treatment for pediatric eczema acral (atopic dermatitis affecting the hands and feet)?

First-Line Treatment for Pediatric Acral Eczema

The first-line treatment for pediatric acral eczema (atopic dermatitis affecting hands and feet) consists of regular emollients combined with appropriate potency topical corticosteroids, with mild to moderate potency preferred for these sensitive areas. 1

Basic Treatment Approach

Skin Care Fundamentals

• Regular emollient use:

  • Apply immediately after bathing to lock in moisture
  • Use liberally and frequently throughout the day
  • Choose fragrance-free, non-irritating formulations 1, 2

• Bathing recommendations:

  • Use lukewarm water (not hot)
  • Add bath oils (0.5 dl per bath) 3
  • Use soap substitutes/dispersible creams instead of regular soaps 1
  • For acute flares, twice-daily "soak-and-seal" baths (15-20 minutes) followed by immediate moisturizer application can significantly improve symptoms 4

Topical Anti-inflammatory Therapy

• Topical corticosteroids (TCS):

  • For acral areas (hands/feet):
    • Start with mild to moderate potency TCS for children 1
    • Apply once or twice daily during flares 5
    • Limit duration of potent TCS on sensitive areas to avoid skin atrophy 1

• Application technique:

  • Apply TCS to affected areas before moisturizer
  • Use only 1-2 times daily (once daily application is as effective as twice daily for potent TCS) 5
  • Apply sufficient quantity (fingertip unit guideline)

Management of Flares

Addressing Secondary Infection

• If signs of bacterial infection present (crusting, weeping):
  • Consider flucloxacillin as first-line antibiotic (S. aureus is most common pathogen) 1
  • Erythromycin for penicillin-allergic patients 1
  • Avoid long-term topical antibiotics due to resistance risk 1

Wet Wrap Therapy

• For moderate to severe flares not responding to standard treatment:
  • Apply TCS then cover with wet bandages
  • Effective short-term second-line treatment 1
  • Monitor for increased risk of skin infections 2

Adjunctive Treatments

Antihistamines

• Sedating antihistamines may help with sleep disturbance from itching 1
• Non-sedating antihistamines have little value for eczema itch unless patient also has urticaria 1

Topical Calcineurin Inhibitors (TCIs)

• Consider for children ≥2 years when TCS is ineffective or inappropriate 1
• Useful as steroid-sparing agents 1
• May cause burning sensation initially

Prevention of Flares

Proactive Therapy

• After clearing eczema, twice-weekly application of TCS or TCI to previously affected areas can prevent relapses 1
• This "weekend therapy" approach significantly reduces flare risk from 58% to 25% 5

Trigger Avoidance

• Identify and avoid individual triggers:
  • Irritants (wool clothing, harsh soaps)
  • Excessive sweating
  • Temperature/humidity changes 1

Common Pitfalls to Avoid

1. Undertreatment due to "steroid phobia" - Appropriate potency TCS used correctly is safe and effective 1
2. Inadequate moisturizer use - Must be applied liberally and frequently
3. Prolonged use of potent TCS on hands/feet - Can cause skin atrophy; use appropriate potency and duration
4. Neglecting secondary infection - Bacterial infection requires prompt antibiotic treatment
5. Long-term topical antibiotic use - Increases risk of resistance and sensitization 1

For acral eczema specifically, pay special attention to the mechanical stress these areas endure and consider occlusive dressings at night to enhance treatment efficacy in severe cases.