What is the recommended treatment for eczema in a 6-year-old patient?

Treatment of Eczema in a 6-Year-Old Patient

For a 6-year-old patient with eczema, the recommended first-line treatment is topical corticosteroids (TCS) of low to medium potency applied reactively to affected areas, along with basic therapy including emollients, avoidance of triggers, and education. 1

Step-by-Step Treatment Approach

Basic Therapy (For All Patients)

• Emollients: Apply liberally at least twice daily, especially after bathing
• Trigger avoidance: Identify and avoid allergens and irritants
• Education: Teach proper skin care and treatment application

Treatment Based on Severity

For Mild Eczema

• Preferred option: Low to medium potency TCS (e.g., hydrocortisone 0.5-1%) applied reactively to affected areas 1
  • Apply no more than 3-4 times daily 2
  • Use for short courses (typically 1-2 weeks)
• Alternative options:
  • Topical calcineurin inhibitor (pimecrolimus)
  • Topical PDE-4 inhibitor (crisaborole)

For Moderate Eczema

• Preferred option: Low to medium potency TCS applied proactively and reactively 1
  • Proactive therapy involves applying TCS to previously affected areas twice weekly to prevent flares
• Other options:
  • Topical calcineurin inhibitors (pimecrolimus or tacrolimus)
  • Topical PDE-4 inhibitor (crisaborole)

For Severe Eczema

• Preferred option: Low to high potency TCS with proactive and reactive therapy 1
• Add-on therapies for very severe cases:
  • Dupilumab (approved for children 6 years and older) 1
  • Short-term oral corticosteroids (<7 days) for acute flares 1

Application Techniques

1. Frequency: Once-daily application of potent TCS is likely as effective as twice-daily application for treating flares 3
2. Order of application: The order of applying emollient and TCS does not significantly affect treatment outcomes - parents can apply in whichever order they prefer 4
3. Wet wrap technique: Consider for acute, severe flares in an inpatient setting (typically 3-5 days) 5

Safety Considerations

1. Potency selection: Use the lowest effective potency to minimize side effects

   • For children, mild to moderate potency is generally preferred
   • Short bursts (3 days) of potent TCS can be as effective as prolonged use (7 days) of mild preparations 6

2. Monitor for adverse effects:

   • Local: skin thinning, striae, telangiectasia
   • Systemic: HPA axis suppression (rare with appropriate use)

3. Precautions for children 7:

   • Children may absorb proportionally larger amounts of TCS
   • Avoid occlusive dressings or tight-fitting diapers/plastic pants when treating diaper area
   • Limit treatment to the least amount compatible with effective therapy

Common Pitfalls to Avoid

1. Corticosteroid phobia: Many parents (72.5%) worry about using TCS, leading to non-compliance (24%) 8

   • Provide clear education about safety and proper use
   • Emphasize that appropriate use has minimal risk of side effects

2. Overuse of potent preparations: Higher potency TCS carry greater risk of adverse effects

   • Reserve potent TCS for short-term use in moderate to severe cases

3. Neglecting basic therapy: Emollients and trigger avoidance are fundamental

   • Maintain consistent emollient use even when eczema is controlled

4. Missing infections: In the presence of infection, appropriate antimicrobial therapy should be added 1

By following this evidence-based approach, most children with eczema can achieve good control of their condition while minimizing the risk of adverse effects from treatment.