What topical ointment is recommended for pediatric patients with rashes secondary to hypersensitivity reactions?

Topical Treatment for Pediatric Rashes Due to Hypersensitivity Reactions

For pediatric patients with rashes secondary to hypersensitivity reactions, mild to moderate potency topical corticosteroids are the first-line treatment, with tacrolimus 0.1% ointment recommended for sensitive areas such as the face and genital regions. 1

First-Line Treatment Options

Topical Corticosteroids

• Mild to moderate potency topical corticosteroids are recommended as first-line therapy for hypersensitivity-related rashes in pediatric patients 1
• For children under 2 years of age, hydrocortisone (mild potency) is appropriate and can be applied to affected areas not more than 3-4 times daily 2
• Children aged 2 years and older can use hydrocortisone following the same application frequency 2
• Younger patients (0-6 years), especially infants, are more vulnerable to hypothalamic-pituitary-adrenal (HPA) axis suppression due to their high body surface area-to-volume ratio compared to older children 3, 1
• High-potency or ultra-high-potency topical corticosteroids should be avoided or used with extreme caution in infants and young children 1

Application Guidelines

• Apply a thin film of the corticosteroid to the affected area once or twice daily 1
• Treatment should not be applied more than twice daily 3
• Duration of treatment should be limited to the shortest period necessary to achieve control of symptoms 1
• For acute flares, a short course (3-7 days) is typically sufficient 1
• Abrupt discontinuation of high-potency corticosteroids should be avoided to prevent rebound flares 3

Alternative Options for Sensitive Areas

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 3, 1
• TCIs are particularly useful for facial and genital rashes where corticosteroids might cause skin atrophy 3
• Pimecrolimus is FDA-approved for children as young as 3 months of age 1
• Tacrolimus 0.1% ointment has shown excellent improvement within 30 days in pediatric patients with facial rashes 3
• TCIs do not cause skin atrophy, making them suitable for long-term use in sensitive areas 3

Adjunctive Treatments

Emollients

• Regular use of emollients has a short and long-term steroid-sparing effect 3
• Apply emollients immediately after bathing when skin is still damp 1
• Use fragrance-free, hypoallergenic emollients to avoid further irritation 1

Antihistamines

• Sedating antihistamines may be useful as short-term adjuncts during severe itching episodes 3, 1
• Non-sedating antihistamines have little value in treating hypersensitivity rashes 3
• Large doses of antihistamines may be required in children for adequate symptom control 3

Special Considerations

Wet Wrap Therapy

• For severe or recalcitrant cases, wet wrap therapy can be considered 3
• This involves applying the topical medication and then covering with damp bandages followed by dry bandages 3
• Duration should be limited to 3-7 days, with possible extension to a maximum of 14 days in severe cases 3, 4

Managing Complications

• Secondary bacterial infections (usually Staphylococcus aureus) require antibiotic treatment 3, 1
• Flucloxacillin is usually the most appropriate antibiotic for treating S. aureus infections 3
• For penicillin-allergic patients, erythromycin is an alternative 3

Safety Considerations and Monitoring

• Provide careful instruction to caregivers on the amount to apply and safe sites for use 3
• Supply limited quantities of medication to prevent overuse 3
• Monitor for signs of skin atrophy, striae, or systemic absorption 3
• The risk of adverse effects increases with higher potency, occlusion, and prolonged use 1
• For patients using calcipotriene/calcipotriol (vitamin D analogs), monitor vitamin D metabolites when applied to large body surface areas 3

Cautions

• Avoid using high-potency corticosteroids on the face, genital areas, and skin folds due to increased risk of skin atrophy 3
• Be aware that hypersensitivity reactions to corticosteroids themselves can occur, though rare (0.3-0.5% prevalence) 5
• Patients with atopic dermatitis are at higher risk for developing allergic contact dermatitis from topical corticosteroids 5