What is the recommended treatment for eczema (atopic dermatitis) in babies?

Treatment of Eczema in Babies

Regular emollients applied liberally at least twice daily plus low-potency topical corticosteroids (hydrocortisone 1%) for flares form the cornerstone of eczema management in babies. 1, 2

First-Line Treatment Strategy

Emollients (Essential Foundation)

• Apply emollients liberally and frequently—at least twice daily and as needed throughout the day 2
• Apply immediately after bathing to lock in moisture when skin is most hydrated 2
• Use emollients regularly even when skin appears clear to maintain barrier function 1
• Choose any formulation (lotion, cream, gel, or ointment) based on parent/child preference, as all types are equally effective 3
• Ointments and creams are suitable for very dry skin or winter use 1

Bathing Technique

• Bathe with lukewarm water for 10-15 minutes 1, 2
• Replace soaps with gentle, dispersible cream cleansers as soap substitutes 2, 4
• Apply emollients immediately after patting skin dry 1

Topical Corticosteroids for Flares

• Use low-potency corticosteroids only (hydrocortisone 1%) for infants and babies 4, 5, 6
• Apply once or twice daily to affected areas until lesions significantly improve 1, 5
• Avoid high-potency or ultra-high-potency corticosteroids in infants due to increased risk of hypothalamic-pituitary-adrenal axis suppression from their high body surface area-to-volume ratio 4, 5
• For face, neck, and skin folds, use only low-potency preparations to prevent skin atrophy 1, 4
• Apply to affected areas not more than 3-4 times daily 6

Second-Line Options for Sensitive Areas

Topical Calcineurin Inhibitors

• Pimecrolimus 1% cream is FDA-approved for babies as young as 3 months and is particularly useful for facial eczema 1, 5
• Tacrolimus 0.03% ointment is approved for children aged 2 years and above 1, 5
• These are steroid-sparing alternatives especially valuable for face and genital regions 4, 5

Emerging Topical Agents

• Crisaborole 2% ointment (PDE-4 inhibitor) is approved for mild to moderate eczema in infants aged 3 months and above 1
• Most common adverse effect is stinging or burning at application site 1

Managing Complications

Secondary Bacterial Infection

• Watch for crusting, weeping, or worsening despite treatment 2, 5
• Flucloxacillin is first-choice antibiotic for Staphylococcus aureus infections 4, 5
• Erythromycin for penicillin-allergic patients 4
• Avoid long-term topical antibiotics due to resistance and sensitization risk 1

Eczema Herpeticum (Herpes Simplex Infection)

• Requires prompt treatment with oral acyclovir 4, 5
• Use intravenous acyclovir for ill, febrile infants 4

Adjunctive Measures

Itch Management

• Sedating antihistamines may help short-term for sleep disturbance caused by itching, primarily at night 2, 4, 5
• Non-sedating antihistamines have little value in atopic eczema 2, 4

Trigger Avoidance

• Use cotton clothing next to skin and avoid wool or synthetic fabrics 2, 4
• Keep fingernails short to minimize scratching damage 2, 4, 5
• Maintain comfortable room temperatures, avoiding excessive heat 2
• Avoid harsh detergents and fabric softeners when washing clothes 2

Wet-Wrap Therapy

• Effective short-term (3-7 days, maximum 14 days) second-line treatment for moderate to severe eczema with topical corticosteroids 1
• Should be considered before systemic immunosuppressive therapies 1

Critical Safety Considerations and Pitfalls

Corticosteroid Safety

• Never use high-potency corticosteroids on infants—risk of systemic absorption and HPA axis suppression is significantly elevated 4, 5
• Provide only limited quantities with specific instructions on safe application sites 2
• Avoid abrupt discontinuation of corticosteroids to prevent rebound flares 2
• Monitor for skin atrophy, striae, or signs of systemic absorption 4

Emollient Safety Concerns

• Emollients may increase risk of skin infections (17 more cases per 1000 infants) 7
• Watch for infant slippage hazards when using emollients 7
• Monitor for stinging or allergic reactions to moisturizers 7
• Note: Recent high-quality evidence shows emollients do not prevent eczema development and may increase food allergy risk, but they remain essential for treating established eczema 8, 7

Dietary Restrictions

• Dietary restriction is worth trying only in selected infants under professional supervision with dietitian consultation 2

Parent Education Essentials

• Demonstrate proper application technique for emollients and medications 2
• Provide written instructions to reinforce verbal guidance 2
• Explain that deterioration in previously stable eczema may indicate infection or contact dermatitis 2
• Reassure parents about safety of appropriate low-potency topical corticosteroid use, as fear of steroids often leads to undertreatment 2