What treatment options are available for skin symptoms?

Treatment Options for Skin Symptoms

For most skin symptoms, start with basic skin care including gentle cleansers, emollients, and topical corticosteroids as first-line therapy, with treatment intensity escalated based on severity and specific diagnosis.

General Skin Care Principles (All Skin Conditions)

• Use gentle, soap-free cleansers and avoid hot water, as soaps and detergents strip natural lipids from the skin surface and hot showers dehydrate the skin, worsening xerosis 1, 2, 3
• Apply emollients and moisturizers daily after bathing to provide a surface lipid film that retards evaporative water loss and maintains skin barrier function 1, 2, 3
• Avoid alcohol-containing preparations (lotions or gels), as they enhance dryness and irritation; instead use oil-in-water creams or ointments 1, 2, 3
• Use high SPF sunscreen (SPF 30 or higher) and avoid excessive sun exposure 1

Topical Corticosteroids: The Cornerstone of Treatment

Mild Skin Conditions

• For mild symptoms, use low to medium potency topical corticosteroids such as hydrocortisone 1% cream applied to affected areas not more than 3-4 times daily 1, 4
• Hydrocortisone 1% is FDA-approved for temporary relief of itching associated with minor skin irritations, inflammation, rashes due to eczema, psoriasis, contact dermatitis, insect bites, and seborrheic dermatitis 4
• Apply twice daily on the first day for acute dermatitis, then reduce to once daily from the second day onward, as plasma levels peak after 24 hours and skin barrier begins to restore 5

Moderate to Severe Conditions

• For moderate symptoms, use low to high potency topical corticosteroids in proactive and reactive therapy 1
• Prednicarbate cream 0.02% can be used for more significant inflammation and erythema 2
• Cream or lotion preparations should be preferred over gels to take advantage of additional moisturization effects 1

Important Caveats

• Avoid long-term use of topical corticosteroids, especially on the face, due to risk of skin atrophy, telangiectasia, and tachyphylaxis 3
• A 2-week course of mild potency steroids can cause transient epidermal thinning that returns to baseline 4 weeks after discontinuation 6
• Use the least potent preparation required to keep symptoms under control 3

Alternative and Adjunctive Topical Therapies

Topical Calcineurin Inhibitors (TCIs)

• For sensitive areas like the face or when repeated application is required, consider pimecrolimus (approved for ages 3 months and above) or tacrolimus (ages 2+ for 0.03%, ages 16+ for 0.1%) 1
• TCIs may be safer than corticosteroids for facial use as they do not cause epidermal thinning 6

Topical Antibiotics

• For inflammatory skin reactions, begin topical antibiotics (erythromycin, metronidazole, or nadifloxacin) twice daily, preferably in cream or lotion formulations 1
• Topical antibiotics should not be used as monotherapy due to risk of bacterial resistance 1
• Systemic antibiotics should only be used if there is evidence of secondary bacterial infection (crusting, weeping, or clinical signs of infection) after taking bacterial swabs 1, 2, 3

Benzoyl Peroxide

• For acneiform skin reactions, benzoyl peroxide is effective and recommended to prevent bacterial resistance, especially when used with antibiotics 1

Topical Retinoids

• For comedonal lesions, topical retinoids (adapalene, tretinoin, or tazarotene) are the core therapy as they are comedolytic and anti-inflammatory 1

Other Agents

• Azelaic acid is useful for postinflammatory dyspigmentation and as adjunctive acne treatment 1
• Topical PDE-4 inhibitors (crisaborole) can be used for mild to moderate conditions in patients ages 3 months and above 1

Symptomatic Relief

Pruritus Management

• For grade 2/3 pruritus, use oral antihistamines such as cetirizine, loratadine, fexofenadine, or clemastine 2, 3
• Topical polidocanol-containing lotions can soothe itching 2
• Antihistamines with sedative properties can be useful as short-term adjuvants during severe flares with intense pruritus 3

Special Considerations

• For lichenified areas, ichthammol (1% in zinc ointment) or paste bandages may be useful 3
• For fisures, propilenglicol 50% in water applied 30 minutes under occlusion nightly, followed by hydrocolloid dressing, can accelerate healing 3

Systemic Therapies (Severe Cases Only)

Oral Corticosteroids

• Routine use of systemic corticosteroids is generally discouraged and should be reserved only for special circumstances 1
• Low dose, short-term oral corticosteroids (<7 days) may be considered for severe acute exacerbations or grade 3 erythema and desquamation 1, 2
• Rebound flare is common upon discontinuation, and recent evidence shows increased risk of severe adverse events even with short-term use 1

Advanced Therapies

• For very severe, refractory cases, consider immunomodulators (cyclosporine, methotrexate, azathioprine), biologics (dupilumab for ages 6+), or phototherapy (not recommended for children under 12) 1

Critical Pitfalls to Avoid

• Never trim cuticles or manipulate skin lesions, as this increases risk of secondary infection 2
• Avoid greasy occlusive creams, as they may facilitate folliculitis and inhibit absorption of wound exudate 1, 2, 3
• Do not undertreat due to fear of steroid side effects, but also avoid overuse 3
• Avoid topical solutions or alcohol-containing gel formulations as they enhance dryness 1
• Look for evidence of clinical infection (crusting, weeping, punched-out erosions suggesting herpes simplex) before starting antibiotics 3
• Avoid neomycin in topical preparations due to risk of sensitization 3

Treatment Algorithm by Severity

Mild: Reactive therapy with low-medium potency topical corticosteroids OR topical calcineurin inhibitors + basic skin care 1

Moderate: Proactive and reactive therapy with low-high potency topical corticosteroids ± topical calcineurin inhibitors ± topical antibiotics + basic skin care 1

Severe/Very Severe: High potency topical corticosteroids + topical calcineurin inhibitors + consider systemic therapies (immunomodulators, biologics, short-term oral corticosteroids <7 days, or phototherapy) + basic skin care 1

All severities require: Emollients, avoidance of triggers, and patient education 1