What is the recommended treatment for infantile eczema?

Treatment of Infantile Eczema

The recommended treatment for infantile eczema is mild to moderate potency topical corticosteroids as first-line therapy, with careful consideration of potency based on severity and affected body areas. 1

First-Line Treatment

Basic Therapy

• Emollients are essential for maintaining skin hydration and should be applied regularly, especially after bathing when the skin is still damp 1
• Avoid irritants such as soaps, detergents, and wool clothing that can exacerbate eczema 1
• Cotton clothing is recommended as it is more comfortable and less irritating 1
• Keep nails short to minimize damage from scratching 1

Topical Corticosteroids

• Use the least potent preparation required to control the eczema 1
• For infants, mild to moderate potency corticosteroids are preferred due to their high body surface area-to-volume ratio, which increases risk of systemic absorption 1
• Application frequency:
  • Apply once or twice daily as directed 1
  • Some newer preparations require only once daily application 1
  • Once daily application of potent corticosteroids is likely as effective as twice daily application 2
• Special considerations:
  • Avoid high-potency or ultra-high-potency corticosteroids in infants due to increased risk of hypothalamic-pituitary-adrenal (HPA) axis suppression 1
  • For facial and genital areas, use only mild potency corticosteroids 1

Topical Calcineurin Inhibitors (TCIs)

• Tacrolimus 0.03% ointment and pimecrolimus 1% cream are effective alternatives for sensitive areas such as the face and genital regions 1
• Pimecrolimus is FDA-approved for children as young as 3 months of age 1, 3
• TCIs do not cause skin thinning, making them suitable for long-term use and sensitive areas 1
• Common side effects include transient burning or stinging at the application site 4

Treatment Algorithm Based on Severity

Mild Eczema

• Basic therapy with regular emollients 1
• Reactive therapy with low to medium potency topical corticosteroids 1
• Alternative: Pimecrolimus 1% cream for sensitive areas 1, 3

Moderate Eczema

• Proactive and reactive therapy with low to medium potency topical corticosteroids 1
• Alternatives: Topical calcineurin inhibitors (pimecrolimus or tacrolimus) 1
• Studies show tacrolimus 0.03% is more effective than 1% hydrocortisone for moderate to severe eczema in children 4, 5

Severe Eczema

• Add-on therapies may be required 1
• Short courses (less than 7 days) of low-dose oral corticosteroids may be considered in severe acute exacerbations, but long-term use is not recommended 1
• Referral to a dermatologist is appropriate for severe or treatment-resistant cases 1

Managing Complications

Infection

• Secondary bacterial infection (usually Staphylococcus aureus) requires antibiotic treatment 1
• Flucloxacillin is typically the first choice for S. aureus infections 1
• Erythromycin may be used for penicillin-allergic patients 1
• Eczema herpeticum (herpes simplex infection) requires prompt treatment with oral acyclovir 1

Pruritus Management

• Sedating antihistamines may be useful as short-term adjuncts during severe itching episodes 1
• Non-sedating antihistamines have little value in atopic eczema 1
• Antihistamines are most effective when given at night to help with sleep disturbance 1

Safety Considerations

• Contrary to common fears, appropriate use of topical corticosteroids in pediatric eczema does not cause atrophy, hypopigmentation, or other serious adverse effects 6
• The risk of adverse effects increases with higher potency, occlusion, and prolonged use 1
• Parents should receive clear instructions on:
  • The amount of medication to apply (fingertip unit method) 1
  • Safe sites for application 1
  • Duration of treatment 1
• Avoid abrupt discontinuation of high-potency corticosteroids to prevent rebound flares 1

Common Pitfalls to Avoid

• Undertreatment due to "steroid phobia" often leads to prolonged and unnecessary eczema exacerbations 6
• Using potent corticosteroids on the face or in skin folds increases risk of adverse effects 1
• Failure to treat secondary infections can lead to treatment resistance 1
• Not providing adequate education about proper application techniques and quantities 1
• Forgetting to emphasize the importance of regular emollient use as the foundation of treatment 1