What is the recommended treatment for eczema in infants?

Treatment of Eczema in Infants

Topical corticosteroids are the mainstay of treatment for infant eczema, with the least potent preparation (hydrocortisone) being recommended as first-line therapy, combined with regular emollient use. 1, 2

First-Line Treatment

Emollients and Skin Care

• Apply emollients regularly after bathing to provide a surface lipid film that retards evaporative water loss from the epidermis 1, 3
• Use a dispersible cream as a soap substitute to cleanse the skin, as soaps and detergents remove natural lipids from the skin surface 1, 3
• Keep infant's nails short to minimize damage from scratching 1, 4
• Avoid irritant clothing such as woollens; cotton clothing is more comfortable and recommended 1

Topical Corticosteroids

• For mild eczema in infants, use mild-potency topical corticosteroids (hydrocortisone) 2
• Apply to affected areas only, not more than 3-4 times daily for children 2 years and older; for children under 2 years, consult a doctor 2
• The basic principle is to use the least potent preparation required to keep the eczema under control 1
• When possible, corticosteroids should be stopped for short periods to minimize side effects 1, 5

Managing Itch and Sleep Disturbance

• Sedating antihistamines are useful as a short-term adjuvant to topical treatment during relapses associated with severe pruritus 1, 4
• Non-sedating antihistamines have little or no value in atopic eczema 1, 4
• Antihistamines should primarily be used at night to help with sleep disruption and avoid daytime sedation 3, 4

Treatment of Secondary Infection

• Antibiotics are important for treating overt secondary bacterial infection 1
• Flucloxacillin is usually the most appropriate antibiotic for treating Staphylococcus aureus, the commonest pathogen 1
• For herpes simplex infection (eczema herpeticum), oral acyclovir should be given early in the course of the disease 1

Practical Application Tips

• Apply emollients after bathing when the skin is still slightly damp 3, 6
• The order of application between emollients and topical corticosteroids does not significantly affect treatment outcomes, though applying emollients first followed by corticosteroids 15 minutes later is commonly recommended 6
• Do not apply topical treatments more than twice daily, as this doesn't improve efficacy but increases risk of side effects 3, 7

When to Refer to a Specialist

• Refer to a specialist if there is diagnostic doubt 1
• Refer if the infant fails to respond to maintenance treatment with mildly potent steroids 1
• Refer when specialist opinion would be valuable in counseling parents 1

Common Pitfalls and Caveats

• Fear of topical corticosteroids often leads to undertreatment of eczema; when used appropriately as per guidelines, adverse effects are minimal 5
• Contrary to popular perceptions, appropriate use of topical corticosteroids in pediatric eczema does not cause atrophy, hypopigmentation, or other feared side effects 5
• The main risk with prolonged use of potent corticosteroids is suppression of the pituitary-adrenal axis with possible interference of growth in children 1, 8
• A short burst of a potent topical corticosteroid (3 days) followed by a mild preparation may be just as effective as prolonged use of a mild preparation alone for controlling moderate eczema 9

Preventive Strategies

• Evidence for the role of breastfeeding and maternal avoidance of allergens during pregnancy in protecting against atopy is conflicting 1
• Early interventions such as breastfeeding, hydrolyzed formulas, and early application of skin emollients may be recommended in high-risk infants, though evidence of their clinical benefits remains equivocal 1