What is the treatment for skin lesions in children 0-7 years old?

Treatment of Skin Lesions in Children 0-7 Years Old

The treatment approach depends critically on the specific diagnosis, but for the most common bacterial skin infections in this age group—impetigo, cellulitis, and abscesses—topical mupirocin 2% ointment is recommended for localized impetigo, while systemic antibiotics covering Staphylococcus aureus and group A Streptococcus are required for more extensive or deeper infections. 1, 2

Initial Assessment and Diagnosis

The first step requires determining whether the lesion is:

• Infectious (bacterial, viral, fungal, or parasitic) versus inflammatory (eczema, psoriasis, contact dermatitis) versus vascular (hemangiomas) versus other (mastocytosis, congenital conditions) 3, 2
• Superficial versus deep, and localized versus spreading 4
• Associated with systemic symptoms (fever, toxicity, SIRS) which dramatically changes management urgency 5

For suspected bacterial infections, distinguish between:

• Purulent lesions (abscesses, bullous impetigo) versus non-purulent (cellulitis, erysipelas) 6
• Localized minor infections versus extensive or complicated infections 1

Treatment by Condition Category

Bacterial Skin Infections

For localized impetigo:

• Mupirocin 2% ointment applied to affected areas 3 times daily for 5-7 days is the first-line topical treatment 1
• This achieves 78% clinical efficacy in pediatric patients aged 2 months to 15 years 1
• Do not use mupirocin for extensive impetigo, purulent cellulitis, abscesses, or signs of systemic toxicity—these require systemic antibiotics 1

For cellulitis or more extensive bacterial infections:

• Systemic antibiotics targeting S. aureus and group A Streptococcus are required 2, 4
• Oral options include beta-lactamase-stable penicillins, second- or third-generation cephalosporins (e.g., cefdinir), or clindamycin if local resistance is low 4
• Mupirocin should never be used as monotherapy for cellulitis 1

For abscesses:

• Incision and drainage is the primary treatment 6
• Add systemic antibiotics if there are signs of surrounding cellulitis, systemic symptoms, or immunocompromise 6

For Staphylococcal Scalded Skin Syndrome (SSSS):

• This is a dermatologic emergency requiring immediate hospitalization 7
• Start with IV beta-lactam antibiotics (e.g., cefazolin) if no type 1 penicillin allergy 8
• Add vancomycin 15 mg/kg/dose IV every 6 hours if the patient is critically ill, not improving on beta-lactams, in a high MRSA prevalence area, or has confirmed MRSA 8
• Consider adding clindamycin 10-13 mg/kg/dose IV every 6-8 hours as adjunctive therapy to stop exotoxin production 8
• Treatment duration is typically 7-14 days guided by clinical response 8
• Critical pitfall: Never use tetracyclines in children <8 years of age 8

Inflammatory Skin Conditions

For atopic dermatitis/eczema:

• Emollients are the foundation of therapy, applied liberally and frequently (3-8 times daily) 9, 3
• For mild-to-moderate flares on the trunk and extremities, use topical corticosteroids (class I-II potency) 9
• For facial and genital psoriasis or eczema, tacrolimus 0.1% ointment is recommended as off-label monotherapy 9
• In children <2 years, use hydrocortisone topical preparations not more than 3-4 times daily, but ask a doctor before use in children <2 years per FDA labeling 10
• Critical caution in children 0-6 years: High-potency or ultra-high-potency topical corticosteroids carry significant risk of HPA axis suppression due to high body surface area-to-volume ratio, especially in infants 9
• For tacrolimus use in inflammatory conditions, monitor for systemic absorption, particularly when applied to large body surface areas 9

For pediatric psoriasis (ages appropriate for treatment):

• Combination calcipotriol/betamethasone dipropionate ointment once daily for up to 4 weeks is recommended for children ≥12 years with mild-to-moderate plaque psoriasis 9
• Rotational therapy alternating topical vitamin D analogues, topical calcineurin inhibitors, emollients, and topical corticosteroids reduces steroid-related adverse effects 9
• Maximum calcipotriol dosing to prevent hypercalcemia: 50 g/week/m² 9
• Monitor vitamin D metabolites with calcipotriene/calcipotriol use 9

Severe Dermatologic Emergencies

For Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis:

• Immediately discontinue the suspected causative drug 9
• Assess airway by pediatric anesthesiologist or intensivist—consider early intubation if clinical signs support this, especially before transfer 9
• Establish peripheral IV access through non-lesional skin if possible and commence appropriate fluid resuscitation 9
• Insert nasogastric tube immediately if the child cannot maintain adequate oral hydration and nutrition 9
• Arrange ophthalmology examination within 24 hours of diagnosis by a specialist experienced in ocular surface diseases in children 9
• Convene a multidisciplinary team including dermatology/burns specialist, pediatric intensive care, ophthalmology, and tissue viability specialists 9

For congenital ichthyoses presenting as collodion baby or harlequin ichthyosis:

• Admit to neonatal intensive care unit immediately 9
• Apply sterile emollients (white petrolatum or water-in-oil emollients) 3-8 times daily to decrease transepidermal water loss 9
• Critical pitfall: Avoid active substances like urea, salicylic acid, or silver sulfadiazine due to risk of percutaneous absorption in neonates 9
• Monitor body weight daily as the best indicator of adequate fluid and nutrient intake 9
• Provide nutritional support through oro- or nasogastric tube if poor sucking due to eclabium 9
• Perform regular bacterial swabs (twice weekly) from flexures, eyes, and IV sites 9
• Prophylactic antibiotics are not recommended for collodion babies but may be considered for harlequin ichthyosis 9

Cutaneous Mastocytosis

For suspected mastocytosis with single or multiple lesions:

• Perform 3mm punch skin biopsy for histology and mutational studies if possible 9
• If single mastocytoma is confirmed, no further studies are required 9
• If urticaria pigmentosa or other forms are diagnosed, obtain baseline serum tryptase and repeat every 6-8 months 9
• Perform abdominal ultrasound if organomegaly is suspected or if there are severe systemic mast cell-mediator symptoms (GI symptoms, flushing, syncope, cyanotic spells) 9
• The natural history for the majority of children is continued improvement, so aggressive cytoreductive therapy should be approached with much caution 9

Viral Infections

For common viral infections (warts, molluscum contagiosum, hand-foot-mouth disease):

• These are typically self-limited 2
• Treatment options for warts include observation, cryosurgery, or topical imiquimod 3

For eczema herpeticum:

• This is a dermatologic emergency requiring immediate antiviral therapy 7
• Hospitalization is often necessary 7

Fungal Infections

For tinea corporis:

• Topical antifungals are usually sufficient 3, 2

For tinea capitis:

• Systemic antifungals are necessary (griseofulvin or terbinafine) because topical agents cannot penetrate hair follicles 3, 2

Parasitic Infections

For scabies:

• Topical permethrin is the treatment of choice 3, 2
• Evidence of negative microscopic skin prep is required before return to activities 9

For head lice:

• Appropriate pharmacologic treatment with permethrin or pyrethrin solutions, followed by reexamination for completeness of response before return to activities 9, 3

Key Clinical Pitfalls to Avoid

• Never use high-potency topical corticosteroids extensively in children 0-6 years without close dermatology follow-up due to HPA axis suppression risk 9
• Never use tetracyclines in children <8 years of age 8
• Never use mupirocin as monotherapy for cellulitis or extensive infections 1
• Never apply urea, salicylic acid, or silver sulfadiazine to neonates with ichthyosis due to percutaneous absorption risk 9
• Never delay recognition of dermatologic emergencies (SSSS, SJS/TEN, eczema herpeticum) as these require immediate intervention 9, 8, 7
• Never assume all skin infections are MRSA—most community-acquired infections in children remain methicillin-susceptible 8, 4