Treatment of Eczema in Children

Topical corticosteroids are the mainstay of treatment for atopic eczema in children and can be used safely if certain precautions are taken. 1, 2

First-Line Treatment

Mild to moderate potency topical corticosteroids are recommended as first-line therapy for infantile and childhood eczema, with careful consideration of potency based on severity and affected body areas 2
Use the least potent preparation required to keep the eczema under control, and when possible the corticosteroids should be stopped for short periods 1
Emollients are essential for maintaining skin hydration and should be applied regularly, especially after bathing when the skin is still damp 2
Avoid irritants such as soaps, detergents, and wool clothing that can exacerbate eczema; cotton clothing is more comfortable and recommended 1
Keep nails short to minimize damage from scratching 1

For mild eczema: low-potency corticosteroids (hydrocortisone 1%) 3
For moderate eczema: low to medium potency corticosteroids 3
For severe eczema: medium to high potency corticosteroids for short periods (3-7 days) 3, 4
Application frequency: once or twice daily application is equally effective for potent topical corticosteroids 4
For sensitive areas such as face, neck, and skin folds, use only low-potency corticosteroids to avoid skin atrophy 3

Tacrolimus 0.03% ointment and pimecrolimus 1% cream are effective alternatives for sensitive areas such as the face and genital regions 2, 3
Pimecrolimus is FDA-approved for children as young as 2 years of age, but should not be used in children under 2 years 5
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 1
Coal tar solution (1% in hydrocortisone ointment) can be effective and does not cause systemic side effects unless used excessively 1

Secondary bacterial infection (usually Staphylococcus aureus) requires antibiotic treatment, with flucloxacillin as the first choice for S. aureus infections; erythromycin may be used for penicillin-allergic patients 1, 2
Eczema herpeticum (herpes simplex infection) requires prompt treatment with oral acyclovir; use intravenous acyclovir for ill, febrile patients 1

Sedating antihistamines may be useful as short-term adjuncts during severe itching episodes, particularly at night 1, 2
Non-sedating antihistamines have little value in atopic eczema 1

Regular use of emollients has a short and long-term steroid-sparing effect 3
For moderate to severe eczema, proactive therapy with twice-weekly application of topical corticosteroids to previously affected areas may prevent relapses 3, 4
Weekend (proactive) therapy probably results in a large decrease in likelihood of a relapse from 58% to 25% 4

Avoid high-potency or ultra-high-potency topical corticosteroids in infants and young children due to increased risk of hypothalamic-pituitary-adrenal (HPA) axis suppression 2, 3
The risk of adverse effects increases with higher potency, occlusion, and prolonged use of topical corticosteroids 2, 3
The order of application of emollient and topical corticosteroid does not significantly affect treatment outcomes; parents can apply topical medications in whichever order they prefer 6
For severe or recalcitrant cases, wet wrap therapy can be considered as a short-term second-line treatment 3, 7
Monitor for signs of skin atrophy, striae, or systemic absorption 3
Abnormal skin thinning is rare but more common with higher-potency topical corticosteroids 4