Topical Treatments for Pediatric Hypersensitivity Rashes
Mild to moderate potency topical corticosteroids are the first-line treatment for hypersensitivity-related rashes in pediatric patients, with careful consideration of potency based on severity and affected body areas. 1
First-Line Treatment Options
- Topical corticosteroids should be selected based on the least potent preparation required to control the rash, using mild to moderate potency formulations for most pediatric hypersensitivity reactions 1
- Apply a thin film of the corticosteroid to affected areas once or twice daily for the shortest duration necessary (typically 3-7 days for acute flares) 1
- Regular use of emollients has both short and long-term steroid-sparing effects and should be applied especially after bathing when skin is still damp 1, 2
- For sensitive areas such as the face and genital regions, consider tacrolimus 0.03% ointment or pimecrolimus 1% cream as effective alternatives 1
Special Considerations for Pediatric Patients
- Children, especially infants, are more susceptible to hypothalamic-pituitary-adrenal (HPA) axis suppression due to their higher body surface area-to-volume ratio 1, 3
- High-potency or ultra-high-potency topical corticosteroids should be avoided or used with extreme caution in infants and young children 1, 3
- Potential adverse effects include growth retardation, delayed weight gain, low plasma cortisol levels, and absence of response to ACTH stimulation 3
- Parents should receive clear instructions on proper application amount, safe application sites, and duration of treatment 2
Alternative Topical Treatments
- Ichthammol (1% in zinc ointment) is less irritant than coal tars and can be applied as an ointment or in paste bandages, particularly useful for lichenified areas 4
- Coal tar solution (1% in hydrocortisone ointment) can be effective and does not cause systemic side effects unless used excessively 4
- For diaper dermatitis due to hypersensitivity reactions, human breast milk has shown comparable efficacy to hydrocortisone 1% ointment in infants 5
Management of Complications
- For secondary bacterial infections (usually Staphylococcus aureus), appropriate antibiotic treatment should be initiated 4, 1
- Flucloxacillin is typically the most appropriate antibiotic for S. aureus infections; erythromycin may be used for penicillin-allergic patients 4
- For herpes simplex infections (eczema herpeticum), prompt treatment with oral acyclovir is necessary; use intravenous acyclovir for ill, febrile patients 4
Adjunctive Treatments
- Sedating antihistamines may be useful as short-term adjuncts during severe itching episodes, particularly at night 4, 1
- Non-sedating antihistamines have little value in managing hypersensitivity-related rashes 4
- For severe or recalcitrant cases, wet wrap therapy can be considered as crisis intervention therapy, typically lasting 3-5 days 1, 6
Treatment Approach Based on Severity
- For mild rashes: Low-potency corticosteroids (1% hydrocortisone) applied once or twice daily for up to 7 days 7
- For moderate rashes: Consider short bursts (3 days) of moderate-potency corticosteroids followed by emollients, which can be as effective as prolonged use of milder preparations 7
- For severe or widespread rashes: Consult with a dermatologist for appropriate management, which may include short-term moderate-potency corticosteroids under close supervision 1
Monitoring and Safety
- Monitor for signs of skin atrophy, striae, or systemic absorption 1
- Avoid occlusive dressings, tight-fitting diapers, or plastic pants on treated areas as these may increase absorption 3
- If HPA axis suppression is noted, attempt to withdraw the drug, reduce application frequency, or substitute a less potent steroid 3
- Patients with atopic dermatitis or stasis dermatitis are at higher risk for developing allergic contact dermatitis from topical corticosteroids themselves 8