First-Line Treatment for Pediatric Eczema Exacerbation
For a child experiencing an eczema exacerbation, initiate treatment with mild to moderate potency topical corticosteroids applied once or twice daily, combined with regular emollient use. 1
Topical Corticosteroid Selection by Age and Severity
Choose corticosteroid potency based on the child's age and disease severity:
Infants and young children (0-6 years): Use mild potency corticosteroids (hydrocortisone 1%) due to their high body surface area-to-volume ratio, which increases risk of systemic absorption and hypothalamic-pituitary-adrenal (HPA) axis suppression 1, 2
Moderate exacerbations: Low to medium potency corticosteroids are appropriate 2
Severe exacerbations: Medium to high potency corticosteroids for short periods (3-7 days) 2
Critical caveat: High-potency or ultra-high-potency corticosteroids should be avoided or used with extreme caution in infants and young children 1, 2
Application Guidelines
Apply topical corticosteroids no more than twice daily - once daily application is equally effective as twice daily for potent corticosteroids 3. Treatment duration should be limited to the shortest period necessary to achieve symptom control 2.
For acute flares, a short course of 3-7 days is typically sufficient 2. Evidence shows that a 3-day burst of potent corticosteroid is as effective as 7 days of mild preparation for mild to moderate eczema 4.
Site-Specific Considerations
Location matters for potency selection:
- Face, neck, and skin folds: Use only low-potency corticosteroids to avoid skin atrophy 2
- Body and limbs: Low to medium potency based on severity 2
- Sensitive areas (face, genitals): Consider topical calcineurin inhibitors (tacrolimus 0.03% or pimecrolimus 1%) as alternatives 1, 2
Essential Adjunctive Therapy
Emollients are non-negotiable - they should be applied regularly, especially after bathing when skin is still damp 1. Regular emollient use has both short and long-term steroid-sparing effects 2. The order of application (emollient first vs. corticosteroid first) does not matter 5.
Managing Complications During Exacerbations
Secondary bacterial infection (usually Staphylococcus aureus):
- First-line: Flucloxacillin 6, 1
- Penicillin allergy: Erythromycin 6, 1
- If β-hemolytic streptococci isolated: Phenoxymethylpenicillin 6
Eczema herpeticum (herpes simplex infection):
- Oral acyclovir given early in disease course 6, 1
- Intravenous acyclovir for ill, febrile patients 6, 1
Pruritus Management
For severe itching episodes: Sedating antihistamines may be useful as short-term adjuncts, particularly at night 1, 2. Large doses may be required in children 6. Non-sedating antihistamines have little value in atopic eczema 1.
Safety Monitoring
Provide clear instructions to caregivers on:
Monitor for adverse effects: The risk increases with higher potency, occlusion, and prolonged use 2. Abnormal skin thinning occurs in approximately 1% of cases, with higher frequency at higher potencies 3.
When to Refer
Refer to specialist if: