What are the recommended ointments for treating eczema in pediatric patients?

Recommended Ointments for Pediatric Eczema

For pediatric eczema treatment, a stepwise approach using topical corticosteroids (TCS) as first-line therapy for flare-ups, along with regular emollient use as basic therapy, is recommended. 1, 2

Basic Therapy (All Severity Levels)

• Emollients should be applied regularly to maintain skin hydration, especially after bathing when skin is still damp 2
• Emollients have both short-term and long-term steroid-sparing effects in mild to moderate atopic dermatitis 1
• Avoid potential triggers including dry skin, excessive sweating, temperature/humidity changes, irritants, allergens, infections, and stress 1

Treatment Based on Severity

Mild Eczema

• Preferred option: Reactive therapy with low to medium potency TCS 1
• Alternative options:
  • Pimecrolimus 1% cream (approved for children as young as 3 months) 1, 3
  • Topical phosphodiesterase-4 (PDE-4) inhibitors like crisaborole 1

Moderate Eczema

• Preferred option: Proactive and reactive therapy with low to medium potency TCS 1
• Alternative options:
  • Topical calcineurin inhibitors (TCIs) - pimecrolimus or tacrolimus 0.03% (approved for children aged 2 years and above) 1
  • Topical PDE-4 inhibitor (crisaborole) 1

Severe to Very Severe Eczema

• First-line: Higher potency TCS for short periods 2
• Add-on therapies for refractory cases:
  • Wet-wrap therapy with TCS (effective short-term second-line treatment) 1, 4
  • For very severe cases: immunomodulators, biologics (dupilumab), or short-course oral corticosteroids (<7 days) 1

Application Guidelines

• Apply TCS once or twice daily to affected areas 2, 5
• Once-daily application of potent TCS is as effective as twice-daily application 5
• The order of application between emollients and TCS does not significantly affect treatment outcomes 6
• For sensitive areas (face, neck, skin folds), use less potent TCS or TCIs to avoid skin atrophy 1, 2

Special Considerations

• Children should be treated with less potent TCS than adults due to higher risk of systemic absorption 1, 2
• Proactive therapy with twice-weekly application of TCS or TCIs to previously affected areas can prevent relapses 1, 5
• Long-term application of topical antibiotics is not recommended due to risk of resistance and skin sensitization 1
• Topical antihistamines have unclear benefits and may increase risk of contact dermatitis 1

Safety Considerations

• Monitor for signs of skin atrophy, striae, or systemic absorption 2
• Risk of adverse effects increases with higher potency, occlusion, and prolonged use 2, 5
• The frequency of abnormal skin thinning is low overall (approximately 1%) but increases with higher potency TCS 5
• Pimecrolimus has shown efficacy in pediatric patients with 35% of treated patients becoming clear or almost clear of signs compared to 18% with vehicle alone 3

Treatment Duration

• For acute flares, a short course (3-7 days) of appropriate potency TCS is typically sufficient 2, 7
• A three-day burst of potent TCS followed by base ointment is as effective as seven days of mild TCS for mild to moderate eczema 7