What topical therapy can I step up to for my 18-month-old with eczema that is not responding to 1% hydrocortisone (HC)?

Stepping Up Topical Therapy for Eczema in an 18-Month-Old Child

For an 18-month-old with eczema not responding to 1% hydrocortisone, you should step up to a moderate-potency topical corticosteroid such as clobetasone butyrate 0.05% (Eumovate) applied twice daily for 1-2 weeks.

Assessment of Current Treatment Failure

When 1% hydrocortisone (mild potency) is not effective for eczema in a toddler, this indicates:

• The inflammatory response requires a stronger anti-inflammatory effect
• The current potency is insufficient for the severity of the condition
• A step-up approach following the corticosteroid potency ladder is appropriate

Recommended Step-Up Treatment

First-Line Step-Up Option:

• Medication: Clobetasone butyrate 0.05% (Eumovate) cream
• Application: Apply thinly twice daily
• Duration: 1-2 weeks until improvement
• Location: Apply to affected areas only

This moderate-potency steroid provides significantly better efficacy while maintaining a reasonable safety profile for a young child 1.

Alternative Step-Up Option:

• Medication: Betamethasone valerate 0.025% (Betnovate-RD) cream
• Application: Apply thinly twice daily
• Duration: 1-2 weeks
• Location: Affected areas only

Application Guidelines

1. Apply a thin layer to affected areas only
2. Use the fingertip unit method for appropriate dosing
3. Avoid application to healthy skin
4. Do not use occlusive dressings unless specifically directed
5. Apply emollients 15-30 minutes before or after steroid application

Adjunctive Treatments

Essential Concurrent Therapy:

• Emollients: Apply fragrance-free, preservative-free emollients frequently throughout the day
• Bathing: Use soap-free cleansers or soap substitutes
• Irritant avoidance: Identify and remove potential triggers (harsh soaps, detergents, fragrances)

For Itching:

• Oral antihistamines can be considered, particularly at bedtime:
  • Cetirizine 2.5mg daily (non-sedating)
  • Hydroxyzine 0.5mg/kg/dose at bedtime (sedating) if sleep disruption is significant

Monitoring and Follow-Up

1. Reassess after 7 days of treatment
2. If improvement occurs, complete the 1-2 week course
3. If no improvement after 7 days, consider:
   • Possible secondary infection requiring antimicrobial treatment
   • Need for dermatology referral for patch testing
   • Possibility of incorrect diagnosis

Safety Considerations for Young Children

1. Limited duration: Keep treatment course to 1-2 weeks
2. Avoid very potent steroids: Never use clobetasol propionate (Dermovate) in this age group
3. Body surface area: Young children have higher body surface area to weight ratio, increasing risk of systemic absorption 1
4. Sensitive areas: Use the moderate-potency steroid only on the body; continue hydrocortisone 1% for face, genitals, and skin folds

When to Consider Further Step-Up or Alternatives

If the moderate-potency steroid fails after 1-2 weeks:

1. Consider short-term use of a potent steroid like betamethasone valerate 0.1% (Betnovate) for severe areas only
2. Consider steroid-sparing alternatives like tacrolimus 0.03% ointment for facial involvement 1
3. Refer to dermatology if no improvement with stepped-up therapy

Common Pitfalls to Avoid

1. Steroid phobia: Undertreatment due to excessive fear of side effects 2
2. Prolonged use: Using moderate-potency steroids continuously for extended periods
3. Inadequate emollient use: Failing to maintain skin barrier with regular moisturization
4. Missing secondary infection: Not recognizing when antibiotics may be needed

Remember that short-term use of appropriate-potency topical corticosteroids is safe and effective when properly monitored, and stepping up therapy when indicated is better than prolonged undertreatment of eczema in children.