First-Line Treatment for Atopic Dermatitis in Infants
The first-line treatment for atopic dermatitis in infants consists of regular application of fragrance-free emollients as the foundation, with low-potency topical corticosteroids (such as 1% hydrocortisone) applied to affected areas during flares. 1
Foundation: Emollients and Skin Care (For All Infants)
Fragrance-free emollients are the cornerstone of therapy and must be applied regularly to all infants with atopic dermatitis, regardless of disease severity. 2, 1
Apply emollients immediately after lukewarm baths (10-15 minutes) using gentle, soap-free cleansers to lock in moisture and restore skin barrier function. 2, 1
Liberal and frequent emollient use has both short-term and long-term steroid-sparing effects in mild to moderate atopic dermatitis. 2, 3
Identify and eliminate triggers including irritants, allergens, excessive sweating, temperature/humidity changes, and ensure cool environmental temperature with smooth, non-irritating clothing. 2, 1
Anti-Inflammatory Treatment: Low-Potency Topical Corticosteroids for Flares
When emollients and trigger avoidance are insufficient, low-potency topical corticosteroids (1% hydrocortisone) are first-line pharmacologic therapy for flares in infants. 2, 1, 4
Apply a thin layer only to affected areas during active flares, not as a general moisturizer, to minimize systemic absorption and local side effects. 1
Infants require less potent topical corticosteroids than older children due to increased risk of adrenal suppression from greater skin surface area-to-body weight ratio and thinner skin. 1
Limit duration of exposure on sensitive areas (face, neck, skin folds) to avoid skin atrophy, which is a particular risk in this age group. 1, 5
Proactive Maintenance for Moderate-to-Severe Cases
- For infants with moderate-to-severe disease experiencing frequent flares, consider proactive therapy with twice-weekly application of low-potency topical corticosteroids to previously affected areas to prevent relapses. 1, 3
Alternative Agents (Age-Specific Restrictions)
Topical calcineurin inhibitors (pimecrolimus, tacrolimus) are NOT approved for infants under 2 years of age and should be avoided. 1, 6
Topical PDE-4 inhibitors (crisaborole) are approved for infants aged 3 months and above with mild-to-moderate atopic dermatitis and may be considered as an alternative to corticosteroids. 1
Pimecrolimus may be used in infants as young as 3 months according to some sources, though this represents off-label use given FDA restrictions. 4
Adjunctive Therapies
Oral antihistamines may be used primarily for their sedative properties to help with sleep disturbance during severe flares, not for direct anti-inflammatory effect. 1
Long-term topical antibiotics are NOT recommended due to resistance and sensitization risk; use only when clinical evidence of bacterial infection exists. 1, 3
Wet-wrap therapy with topical corticosteroids may be considered for short periods in severe cases as crisis intervention. 1, 5
Critical Pitfalls to Avoid
Never use medium, high, or ultra-high potency topical corticosteroids as first-line in infants due to significantly increased risk of systemic absorption and HPA axis suppression. 1
Do not apply topical corticosteroids as a general moisturizer to unaffected skin; reserve for active lesions only. 1
Avoid abrupt discontinuation after prolonged daily use; transition to proactive twice-weekly maintenance or taper gradually. 3
Do not undertreat due to "steroid phobia"—appropriate use of low-potency agents is safe and necessary for disease control. 2
When to Refer
If the condition worsens despite appropriate emollient use and low-potency topical corticosteroids, refer to a pediatric dermatologist. 1
If signs of secondary bacterial infection (impetiginization) or eczema herpeticum develop and do not respond to initial treatment, urgent referral is warranted. 1
For severe, refractory disease requiring consideration of systemic therapies, specialist referral is essential. 1