First-Line Treatment for Dermatitis
Topical corticosteroids applied twice daily to affected areas are the first-line treatment for dermatitis, combined with liberal daily use of emollients to the entire body. 1, 2
Initial Management Approach
Topical Corticosteroid Selection
- Use the least potent preparation required to control symptoms while achieving adequate disease control 1
- For body and extremities: medium to high-potency topical steroids (e.g., triamcinolone, clobetasol) 3
- For facial dermatitis: low-potency hydrocortisone to avoid skin atrophy 3
- Apply twice daily during acute flares 1
- Hydrocortisone butyrate 0.1% has demonstrated safety even in children as young as 3 months with extensive disease 4, 5
Essential Adjunctive Measures
- Apply emollients at least once daily to the whole body, preferably oil-in-water creams or ointments rather than alcohol-containing lotions 1
- Apply emollients after bathing for maximum effectiveness 1
- Use dispersible cream as a soap substitute for cleansing to prevent further skin drying 1
- Keep nails short to prevent secondary infection from scratching 1
- Avoid irritant clothing such as wool; wear cotton clothing instead 1
Alternative First-Line Options for Specific Sites
Facial and Intertriginous Areas
Topical calcineurin inhibitors (tacrolimus 0.1% ointment or pimecrolimus) are recommended as first-line therapy for face and genital regions to avoid corticosteroid-related atrophy 3
- Tacrolimus shows clearance of facial dermatitis within 2 weeks in pediatric patients 3
- These agents can be used in conjunction with topical corticosteroids as first-line treatment 2
Symptom-Specific Management
Pruritus Control
- For severe itching with sleep disturbance: oral antihistamines with sedative properties (diphenhydramine or clemastine) as short-term adjuvant therapy 1
- Non-sedating antihistamines have little value in controlling dermatitis-associated pruritus and are not recommended 1, 2
- Topical polidocanol cream can help relieve itching 1
Secondary Infections
- For bacterial infection (most commonly Staphylococcus aureus): flucloxacillin or appropriate antistaphylococcal antibiotics 1, 2
- For eczema herpeticum: oral acyclovir early in disease course; use intravenous acyclovir for ill, febrile patients 1
Important Caveats
Avoid long-term continuous use of topical corticosteroids due to risk of skin atrophy, telangiectasia, and connective tissue suppression 3, 6. Instead, consider proactive therapy: long-term, low-dose intermittent application of anti-inflammatory agents to previously affected skin areas combined with ongoing emollient treatment of unaffected skin 7.
Sedative antihistamines used long-term may predispose to dementia and should be avoided except in palliative care settings 3.