What to do if a toddler's red cheek rash worsens with topical corticosteroid (steroid) ointment?

Red Cheek Rash Worsening with Steroid Ointment in Toddler

Stop the topical corticosteroid immediately and refer to a dermatologist, as worsening with steroid treatment suggests either steroid allergy, steroid-induced perioral dermatitis, or an infectious process that requires specialized evaluation. 1, 2

Immediate Actions

Discontinue the steroid ointment completely. When a topical corticosteroid fails to control or worsens a skin condition, the primary considerations are wrong diagnosis, steroid allergy, or secondary infection—not inadequate potency. 2 In toddlers with facial rashes that worsen with steroids, continuing the medication can perpetuate the problem. 2, 3

Evaluate for secondary bacterial infection. Facial eczema that worsens despite appropriate steroid use may indicate bacterial superinfection, typically with Staphylococcus aureus. 4, 1 Look for yellow crusting, weeping, pustules, or increased pain rather than just itching. 4 If infection is suspected, obtain bacterial cultures and start oral flucloxacillin (or erythromycin if penicillin-allergic) for at least 14 days. 4

Understanding Why Steroids May Worsen the Rash

Steroid allergy is an underrecognized cause of treatment failure. Contact dermatitis from topical corticosteroids is difficult to diagnose because symptoms overlap with the underlying skin disease. 2 The face is one of the most commonly affected areas for steroid allergy. 2 Risk factors include frequent, long-term application in patients with atopic dermatitis or contact dermatitis. 2

Steroid-induced perioral dermatitis or steroid addiction/dependence can develop, particularly on facial skin. 3 This manifests as red, burning skin that paradoxically worsens when steroids are applied but flares when they're stopped—creating a cycle of dependence. 3

Cross-reactivity between different steroids is common, so switching to another topical corticosteroid often fails. 2 Complete cessation may be the best solution, though withdrawal can be challenging. 2

Recommended Management Algorithm

Step 1: Refer to dermatology within 2-4 weeks. Guidelines explicitly recommend specialist referral when there is no improvement or worsening after appropriate first-line topical corticosteroid treatment. 1 A dermatologist can provide patch testing to identify contact allergens (including the steroid itself) and develop a tailored treatment plan. 1

Step 2: Maintain basic skin care while awaiting specialist evaluation:

• Use soap-free cleansers only 1
• Apply fragrance-free emollients liberally, especially after bathing 1
• Avoid hot water, which can worsen inflammation 4

Step 3: Consider alternative topical therapy for facial eczema:

• Topical calcineurin inhibitors (tacrolimus 0.03% or 0.1%) are preferred for facial dermatitis in children aged 2 years and older as they avoid steroid-related complications. 4 These are particularly appropriate for sensitive areas like the face. 4
• Apply twice daily until significant improvement, then consider proactive therapy. 4
• Common side effects include burning and stinging at application, which typically resolve. 4

Step 4: Address severe pruritus if present:

• Short-term sedating antihistamines at bedtime can help break the itch-scratch cycle. 4, 1
• Large doses may be required in children. 4
• Non-sedating antihistamines have little value in eczema. 4

Critical Pitfalls to Avoid

Do not increase steroid potency. The instinct to escalate to higher-potency steroids when treatment fails is dangerous on facial skin and will worsen steroid allergy or dependence. 2, 3

Do not use high-potency steroids on the face. Facial skin is highly sensitive, and toddlers have increased risk of systemic absorption and HPA axis suppression due to their high body surface area-to-volume ratio. 4

Do not abruptly stop high-potency steroids without transition. If a potent steroid was being used, abrupt discontinuation can cause rebound flare. 4 However, in this case of worsening with treatment, the benefit of stopping outweighs this risk.

Consider eczema herpeticum if vesicles or punched-out erosions are present. This requires immediate oral acyclovir treatment. 4 Systemic corticosteroids should be avoided in eczema herpeticum as they are associated with worse outcomes. 5

Follow-Up Timeline

Reassess within 2 weeks of stopping the steroid and initiating alternative management. 1 If improvement occurs, continue treatment for 4-6 weeks total. 1 If no improvement or continued worsening, expedite the dermatology referral. 1