What are the treatment options for pediatric eczema?

Treatment Options for Pediatric Eczema

The stepwise treatment approach for pediatric eczema should begin with emollients and topical corticosteroids (TCSs) of appropriate potency based on disease severity, with topical calcineurin inhibitors (TCIs) as steroid-sparing alternatives for sensitive areas and maintenance therapy.

Basic Therapy for All Severity Levels

• Emollients: Apply liberally at least twice daily, especially after bathing

  • Use fragrance-free formulations to maintain skin barrier function 1
  • Regular use has both short-term and long-term steroid-sparing effects 2

• Trigger avoidance: Identify and eliminate allergens and irritants that may cause flare-ups 2, 1

• Education: Comprehensive education on disease management can reduce severity and improve quality of life 2

Mild Eczema Treatment

• Preferred option: Reactive therapy with low to medium potency TCSs 2

  • Hydrocortisone 0.1-2.5% is safe for children as young as 2 years 3
  • Apply to affected areas no more than 3-4 times daily 3

• Alternative options:

  • Topical calcineurin inhibitors (TCIs) like pimecrolimus 2
  • Topical PDE-4 inhibitors (crisaborole) 2

Moderate Eczema Treatment

• Preferred options: Proactive and reactive therapy with low to medium potency TCSs 2

  • Once daily application is as effective as twice daily for potent TCSs 4

• Alternative options:

  • TCIs (pimecrolimus or tacrolimus) 2
    • Tacrolimus 0.03% ointment applied once or twice daily is more efficacious than 1% hydrocortisone acetate in children with moderate to severe atopic dermatitis 5
  • Topical PDE-4 inhibitor (crisaborole) 2

Severe to Very Severe Eczema Treatment

• First-line: Proactive and reactive therapy with TCSs (low to high potency) 2

  • Short bursts (3-5 days) of potent TCSs may be as effective as prolonged use of mild preparations 6
  • Caution with potent TCSs in children due to increased risk of systemic absorption 7, 8

• Second-line/Add-on therapy for refractory cases:

  • Wet-wrap therapy for 3-7 days (up to 14 days in severe cases) 2, 1, 9
  • Dupilumab (approved for patients aged 6 years and above) 2
  • Immunomodulators (cyclosporin, methotrexate, azathioprine) for very severe cases 2
  • Phototherapy (not recommended for children younger than 12 years) 2, 1
  • Short courses of oral corticosteroids (<7 days) 2

Special Considerations for Sensitive Areas

• Face, neck, and skin folds:
  • TCIs are preferred over TCSs for sensitive areas to avoid skin atrophy 2, 1
  • If TCSs are used, limit duration of exposure to potent TCSs 2
  • Low-potency TCSs (hydrocortisone 0.1-2.5%) can be used for short-term treatment 1

Maintenance Therapy

• Proactive therapy: Twice-weekly application of TCSs or TCIs to previously affected areas helps prevent relapses in moderate to severe eczema 2, 1, 4
  • Weekend (proactive) therapy reduces likelihood of relapse from 58% to 25% 4

Important Precautions

• Monitoring: Children are particularly susceptible to TCS-induced HPA axis suppression due to larger skin surface area to body weight ratio 7, 8

  • Signs include growth retardation, delayed weight gain, and low plasma cortisol levels 7, 8

• Avoiding common pitfalls:

  • Do not use potent TCSs on the face for prolonged periods 1
  • Long-term application of topical antibiotics is not recommended due to increased risk of resistance and sensitization 2
  • Topical antihistamines are not recommended due to risk of contact dermatitis 2
  • Order of application of emollients and TCSs does not significantly affect treatment outcomes 10

Adjunctive Therapy

• Oral antihistamines: May help reduce pruritus as adjunctive therapy 2, 1
• Antibiotics: Consider only in children with clinical evidence of bacterial infection 2

By following this stepwise approach and adjusting treatment based on disease severity, most pediatric eczema cases can be effectively managed while minimizing potential adverse effects from medications.