What is the emollient of choice for pediatric patients with eczema?

Emollient Selection for Pediatric Eczema

Liberal use of fragrance-free emollients applied multiple times daily (3-8 times) is the cornerstone of basic therapy for pediatric eczema, preferably applied immediately after bathing to lock in moisture. 1, 2

First-Line Emollient Therapy

Emollients form the foundation of eczema management in children and should be used regardless of disease severity:

• Characteristics of ideal emollients:
  • Fragrance-free formulations
  • Applied liberally and frequently (3-8 times daily)
  • Used even when skin appears normal
  • Applied immediately after bathing to trap moisture

Formulation Selection

While there is no single "best" emollient for all children with eczema, the following considerations can guide selection:

• Patient preference and adherence: The most effective emollient is one that the child and family will actually use consistently
• Climate and season:
  • Ointments: Better for very dry skin and winter months
  • Creams: Good balance between moisturization and cosmetic acceptability
  • Lotions: May be preferred in hot, humid weather but generally provide less moisturization
  • Gels: Alternative option with variable acceptance

Practical Application Tips

• Quantity: Prescribe adequate amounts to encourage liberal use
• Technique: Demonstrate proper application technique to parents/caregivers
• Timing: Apply immediately after bathing while skin is still slightly damp
• Frequency: Multiple applications daily (3-8 times) for optimal barrier protection

Safety Considerations

• Avoid potential allergens: Many children's products (93%) contain at least one potential allergen 3
• Watch for signs of contact dermatitis: Deterioration in previously stable eczema may indicate development of contact dermatitis to emollient ingredients 1
• Fragrance-free formulations: Preferred to minimize risk of sensitization
• Patch testing: Consider for patients with persistent or recalcitrant eczema that fails to respond to appropriate treatment 2

Evidence for Effectiveness

Emollients have demonstrated effectiveness as first-line treatment for pediatric eczema:

• They decrease symptoms and reduce the need for topical steroids 4
• When used in combination with topical corticosteroids, emollients enhance treatment efficacy (80% vs 70% improvement; p<0.01) 5
• They form part of the basic therapy in all evidence-based treatment algorithms 1

Common Pitfalls to Avoid

• Insufficient quantity: Underprescribing leads to inadequate application
• Infrequent application: Emollients should be applied multiple times daily
• Fragranced products: May cause sensitization and worsen eczema
• Stopping during disease remission: Emollients should be continued even when skin appears normal
• Ignoring patient preference: Poor acceptability leads to poor adherence

Comprehensive Management

While emollients are foundational, comprehensive eczema management includes:

• Education: Explain proper application techniques and importance of consistent use
• Trigger avoidance: Help identify and eliminate triggering substances
• Infection prevention: Consider antiseptic washes for erosive lesions
• Topical anti-inflammatory therapy: Add topical corticosteroids or calcineurin inhibitors as needed based on disease severity

Remember that emollient therapy is not a cure but a critical component of ongoing management to maintain skin barrier function and prevent flares in pediatric eczema.