What is the treatment for a pediatric patient with raised bumps, burning, itching, and swelling on the face?

Treatment for Pediatric Patient with Raised Bumps, Burning, Itching, and Swelling on the Face

The first-line treatment for a pediatric patient with raised bumps, burning, itching, and swelling on the face is a combination of emollients as baseline therapy with mild topical corticosteroids for symptom control, while identifying and avoiding potential triggers.

Diagnosis Considerations

• The clinical presentation suggests atopic eczema, which is diagnosed based on an itchy skin condition plus three or more of the following: history of itchiness in skin creases, history of atopy, general dry skin, visible flexural eczema, and early onset 1
• Facial involvement in children under 4 years commonly presents as eczema affecting the cheeks or forehead 1
• Secondary bacterial or viral infection should be considered if there is crusting, weeping, or grouped punched-out erosions 1
• Alternative diagnoses like allergic contact dermatitis or urticaria should be considered based on the pattern and timing of the rash 2, 3

First-Line Treatment Approach

• Emollients should be applied liberally and frequently as the foundation of treatment to maintain skin hydration 4
• Apply emollients immediately after bathing to lock in moisture when the skin is most hydrated 4
• For mild to moderate facial eczema, use a low-potency topical corticosteroid such as hydrocortisone 1% 5
• For children 2 years and older, apply hydrocortisone to affected areas no more than 3-4 times daily 5
• For children under 2 years of age, consult a doctor before applying hydrocortisone 5

Bathing and Skin Care

• Replace soaps with gentle, dispersible cream cleansers as soap substitutes to prevent further drying of the skin 1, 4
• Use lukewarm water for bathing and limit bath time to 5-10 minutes 4
• Keep the child's fingernails short to minimize damage from scratching 1, 4
• Use cotton clothing and avoid wool or synthetic fabrics that may irritate the skin 1

Managing Specific Areas

• For facial involvement, topical calcineurin inhibitors (TCIs) like tacrolimus 0.1% ointment are recommended as an alternative to corticosteroids, especially for sensitive areas 1
• TCIs can be particularly effective for facial psoriasis and eczema, with studies showing clearance within 2 weeks 1
• When using topical corticosteroids on the face, use the least potent effective formulation to minimize side effects 4

Managing Infection

• If bacterial infection is suspected (crusting, weeping), obtain bacterial cultures and consider appropriate antibiotic therapy 1, 4
• For herpes simplex infection (grouped vesicles or erosions), prompt treatment with oral acyclovir is needed 4

Antihistamines

• Sedating antihistamines may be helpful short-term for sleep disturbance caused by itching 4
• Non-sedating antihistamines have limited value in managing atopic eczema but may help if urticaria is suspected 4, 3

Parent Education

• Provide clear instructions on proper application of treatments 1
• Demonstrate how to apply emollients and medications correctly 1
• Explain that deterioration in previously stable skin condition may indicate infection or contact dermatitis 1
• Reassure parents about the safety of appropriate topical corticosteroid use, as fear of steroids often leads to undertreatment 1

Cautions and Monitoring

• High-potency or ultra-high-potency topical corticosteroids should be used with caution in children, especially infants, due to their high body surface area-to-volume ratio 1
• Follow patients closely to ensure proper use and monitor for overuse and adverse effects of topical corticosteroids 1
• Provide only limited quantities of topical corticosteroids and give specific instructions on safe application sites 1
• Be aware of potential rebound flare if high-potency corticosteroids are abruptly discontinued 1

When to Consider Referral

• If the condition does not respond to first-line management 4
• If there is suspicion of allergic contact dermatitis requiring patch testing 6, 7
• If systemic therapy is being considered for severe cases 8, 7