What is the recommended treatment for pediatric eczema?

Treatment of Pediatric Eczema

The recommended treatment for pediatric eczema involves a stepwise approach starting with emollients and topical corticosteroids as first-line therapy, with additional treatments added based on disease severity and response. 1

Basic Therapy (For All Severity Levels)

• Emollients should be applied regularly, especially after bathing when the skin is still damp, to maintain skin hydration and barrier function 1
• Education about avoiding triggers such as allergens, scratching, environmental irritants, and infections is essential for effective management 2
• Keep nails short to minimize damage from scratching 1
• Avoid irritants such as harsh soaps, detergents, and wool clothing; cotton clothing is recommended as it is less irritating 1

Mild Eczema

• Reactive therapy with low to medium potency topical corticosteroids (TCSs) is the preferred first-line treatment 2
• Alternative options include topical calcineurin inhibitors (TCIs) such as pimecrolimus or topical PDE-4 inhibitors like crisaborole 2
• For children under 2 years of age, hydrocortisone (mild potency) should be applied to affected areas no more than 3-4 times daily 3

Moderate Eczema

• Proactive and reactive therapy with low to medium potency TCSs is recommended 2
• Alternative options include TCIs (pimecrolimus or tacrolimus) or topical PDE-4 inhibitors 2
• Once-daily application of potent TCSs is as effective as twice-daily application, which can help minimize adverse effects 4

Severe Eczema

• Proactive and reactive therapy with low to high potency TCSs or tacrolimus is the preferred treatment 2
• For severe cases unresponsive to topical therapy, add-on treatments may include:
  • Immunomodulators (cyclosporine, methotrexate, azathioprine) 2
  • Biologics (dupilumab) 2
  • Short-term, low-dose oral corticosteroids (<7 days) 2
  • Phototherapy (not recommended for children younger than 12 years) 2

Topical Corticosteroid Use

• Use the least potent preparation required to control the eczema 1
• For infants and young children, mild to moderate potency corticosteroids are preferred due to their higher body surface area-to-volume ratio, which increases risk of systemic absorption 1, 5
• Apply once or twice daily as directed 1, 4
• Weekend therapy (proactive approach) can help prevent flares after initial control is achieved 4

Special Considerations

Managing Complications

• Secondary bacterial infections (usually Staphylococcus aureus) require antibiotic treatment 1
• Eczema herpeticum (herpes simplex infection) requires prompt treatment with systemic antiviral medications 2
• Systemic antibiotics should only be used in patients with clinical evidence of bacterial infection, not for uninfected or colonized dermatitic skin 2

Pruritus Management

• Short-term, intermittent use of sedating antihistamines may be beneficial for sleep disturbance due to itching but should not replace proper eczema treatment 2
• Non-sedating antihistamines have limited value in managing atopic eczema 1

Safety Considerations

• Pediatric patients may demonstrate greater susceptibility to topical corticosteroid-induced HPA axis suppression than adults 5
• Risks of adverse effects increase with higher potency, occlusion, and prolonged use of topical corticosteroids 5
• Manifestations of adrenal suppression in children include linear growth retardation, delayed weight gain, low plasma cortisol levels, and absence of response to ACTH stimulation 5
• Administration of topical corticosteroids to children should be limited to the least amount compatible with an effective therapeutic regimen 5
• Avoid tight-fitting diapers or plastic pants on children being treated in the diaper area, as these can act as occlusive dressings 5

Emerging Therapies

• Calcineurin inhibitors represent a newer generation of topical treatments for pediatric eczema that can be used as alternatives to topical corticosteroids, especially on sensitive areas like the face and genital regions 1, 6
• Pimecrolimus is FDA-approved for children as young as 3 months of age 1
• Tacrolimus 0.03% ointment is approved for children aged 2 years and above 2