Treatment of Pediatric Eczema
Basic Therapy for All Patients
All children with eczema require regular emollient application and trigger avoidance as the foundation of treatment, regardless of severity. 1, 2
- Apply emollients liberally, especially immediately after bathing while skin is still damp, to maintain skin hydration and barrier function 2
- Educate families about avoiding specific triggers: allergens, scratching, environmental irritants (harsh soaps, detergents, wool clothing), weather extremes, infections, and stress 1
- Keep nails short to minimize scratch-induced skin damage 2, 3
- Use cotton clothing instead of wool or synthetic fabrics 2, 3
Stepwise Treatment Algorithm by Severity
Mild Eczema
For mild eczema, use low to medium potency topical corticosteroids (TCSs) applied reactively to flares as first-line treatment. 1, 2
- First-line: Low to medium potency TCSs applied reactively (only during flares) 1, 2
- Alternative options: Topical calcineurin inhibitors (pimecrolimus) or topical PDE-4 inhibitors (crisaborole) 1, 2
- Pimecrolimus is FDA-approved for children as young as 3 months of age 2, 3
- Crisaborole is approved for patients aged 3 months and above 1
Moderate Eczema
For moderate eczema, use both proactive (maintenance) and reactive (flare) therapy with low to medium potency TCSs. 1, 2
- Preferred: Proactive and reactive therapy with low to medium potency TCSs 1
- Alternative options: Topical calcineurin inhibitors (pimecrolimus or tacrolimus 0.03%) or topical PDE-4 inhibitors 1, 2
- Tacrolimus 0.03% ointment is approved for children aged 2 years and above 1, 2
- Consider wet-wrap therapy with TCSs for 3-7 days (maximum 14 days) as effective short-term second-line treatment 1
Severe to Very Severe Eczema
For severe eczema, use proactive and reactive therapy with low to high potency TCSs or tacrolimus, with add-on systemic therapies for refractory cases. 1, 2
- Preferred: Proactive and reactive therapy with low to high potency TCSs or tacrolimus 1
- Add-on therapies for refractory cases:
- Dupilumab (biologic): First-line systemic therapy for severe AD refractory to topical treatment; approved for patients aged 6 years and above 1
- Immunomodulators: Cyclosporin, methotrexate, or azathioprine (all off-label use) 1
- Short-term oral corticosteroids: Less than 7 days only; long-term use not recommended due to unfavorable risk-benefit profile 1
- Phototherapy (narrowband UVB): Not recommended for children younger than 12 years due to unclear long-term safety 1
Topical Corticosteroid Application Guidelines
Potency Selection by Age and Location
Infants and young children require less potent TCSs than adults due to increased risk of systemic absorption and HPA axis suppression. 1, 3, 4
- Infants and young children: Use mild to moderate potency TCSs only 1, 3, 4
- Sensitive areas (face, neck, skin folds, genital regions): Limit duration of potent TCS exposure to avoid skin atrophy; consider TCIs as steroid-sparing alternatives 1, 2
- Trunk and extremities: Low to medium potency TCSs can be used for longer periods for chronic AD 1
Application Frequency
Apply potent topical corticosteroids once daily rather than twice daily—effectiveness is equivalent. 5
- Once daily application of potent TCSs is as effective as twice daily application for treating eczema flares 5
- Apply to affected areas not more than 3 to 4 times daily for hydrocortisone (low potency) 6
Proactive (Maintenance) Therapy
Use twice-weekly application of TCSs or TCIs to previously affected areas to prevent relapses in moderate to severe eczema. 1, 5
- Weekend (proactive) therapy with TCSs reduces relapse likelihood from 58% to 25% compared to reactive-only use 5
- Apply to previously affected skin areas twice weekly even when clear to maintain remission 1
Adjunctive Treatments
Antihistamines
Oral antihistamines serve as adjuvant therapy for reducing pruritus but should not replace proper eczema treatment. 1, 2
- Sedating antihistamines may be beneficial short-term for sleep disturbance due to itching 1, 2, 3
- Non-sedating antihistamines have limited value in managing atopic eczema 2, 3
- Topical antihistamines are not recommended due to insufficient efficacy evidence and increased risk of contact dermatitis 1
Infection Management
Use systemic antibiotics only when clinical evidence of bacterial infection exists, not for colonized or uninfected skin. 1, 2
- Secondary bacterial infections (usually Staphylococcus aureus) require systemic antibiotics; flucloxacillin is first choice 3
- Long-term topical antibiotics are not recommended due to increased resistance and sensitization risk 1
- Intranasal mupirocin and bleach baths may reduce disease severity in moderate to severe AD with secondary infection 1
- Eczema herpeticum (herpes simplex infection) requires prompt treatment with oral acyclovir 2, 3
Critical Safety Considerations
Avoiding Adverse Effects
The risk of HPA axis suppression and skin atrophy increases with higher potency, larger surface area application, prolonged use, and occlusive dressings. 4, 7
- Children absorb proportionally larger amounts of topical corticosteroids due to higher body surface area-to-volume ratio, making them more susceptible to systemic toxicity 4, 7
- Avoid high-potency or ultra-high-potency corticosteroids in infants due to increased risk of HPA axis suppression 3
- Do not use clobetasol (very potent TCS) in children under 12 years of age 7
- Avoid tight-fitting diapers or plastic pants in the diaper area as these constitute occlusive dressings 4
- Monitor for signs of HPA axis suppression (linear growth retardation, delayed weight gain, low plasma cortisol levels) in children on chronic topical corticosteroid therapy 4, 7
Application Instructions
- Do not bandage or occlude treated areas unless specifically directed 4, 7
- Avoid contact with eyes 4
- Avoid abrupt discontinuation of high-potency corticosteroids to prevent rebound flares 3