What topical steroid is recommended for pediatric patients with eczema?

Topical Steroid Recommendations for Pediatric Eczema

For pediatric patients with eczema, mild to moderate potency topical corticosteroids are recommended as first-line therapy, with low-potency hydrocortisone 1% being the safest option for most children, especially for sensitive areas and younger patients. 1

Recommended Topical Corticosteroid Selection by Age and Severity

• Infants and young children (0-2 years):

  • Low-potency topical corticosteroids (hydrocortisone 1%) for all body areas 1, 2
  • Apply to affected area not more than 3-4 times daily 2
  • Duration should be limited to the shortest period necessary (typically 3-7 days) 1, 3

• Children (2+ years):

  • Mild eczema: Low-potency corticosteroids (hydrocortisone 1%) 4
  • Moderate eczema: Low to medium potency corticosteroids 4
  • Severe eczema: Medium to high potency corticosteroids for short periods (3-7 days) 4, 1
  • Apply once or twice daily (twice daily application offers no significant advantage over once daily for potent corticosteroids) 5

Application Guidelines

• Apply a thin film of corticosteroid to affected areas 1
• Treatment should not be applied more than twice daily 4, 1
• For acute flares, a short course (3-7 days) is typically sufficient 1, 6
• Once daily application of potent topical corticosteroids is as effective as twice daily application 5

Special Considerations for Different Body Areas

• Face, neck, and skin folds: Use only low-potency corticosteroids to avoid skin atrophy 4
• Body and limbs: Low to medium potency corticosteroids based on severity 4
• For sensitive areas (face, genital regions): Consider topical calcineurin inhibitors as alternatives:
  • Tacrolimus 0.03% ointment (for children 2+ years) 4, 1
  • Pimecrolimus 1% cream (for children 3+ months in Taiwan) 4, 1

Maintenance and Prevention

• Regular use of emollients has a short and long-term steroid-sparing effect 4
• For moderate to severe eczema, proactive therapy with twice-weekly application of topical corticosteroids to previously affected areas may prevent relapses 4, 5
• Weekend (proactive) therapy reduces likelihood of relapse from 58% to 25% 5

Safety Considerations

• Children are particularly vulnerable to hypothalamic-pituitary-adrenal axis suppression due to their high body surface area-to-volume ratio 1
• High-potency or ultra-high-potency topical corticosteroids should be avoided or used with extreme caution in infants and young children 1
• When used appropriately, topical corticosteroids do not cause atrophy, hypopigmentation, or other feared side effects 7
• The risk of abnormal skin thinning is low (approximately 1%) and increases with higher potency corticosteroids 5

Alternative Approaches for Resistant Cases

• Wet-wrap therapy with topical corticosteroids is an effective short-term second-line treatment for moderate to very severe eczema 4, 3
• For secondary bacterial infections, appropriate antibiotic treatment should be initiated 4, 1
• Ichthammol (1% in zinc ointment) can be useful for lichenified areas 4, 1

Order of Application with Emollients

• The order of application of emollients and topical corticosteroids does not significantly affect treatment outcomes 8
• Allow 15 minutes between applications of topical corticosteroids and emollients 8