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

Treatment of Eczema in Infants

Liberal application of emollients at least twice daily combined with low-potency topical corticosteroids (hydrocortisone 1%) for flares is the cornerstone of eczema management in infants. 1

First-Line Treatment Strategy

Emollients (Essential Foundation)

• Apply emollients liberally at least twice daily and as needed throughout the day to maintain skin barrier function 1
• Apply immediately after bathing when skin is most hydrated to lock in moisture 1
• Ointments and creams work best for very dry skin or winter use 1
• Emollients provide a surface lipid film that retards evaporative water loss from the epidermis 2
• Bathing is useful for cleansing and hydrating the skin, and parents should choose the most suitable bath oil and bathing regimen 2

Topical Corticosteroids for Active Flares

• Use only low-potency corticosteroids (hydrocortisone 1%) in infants, applied once or twice daily to affected areas until lesions significantly improve 1
• Topical corticosteroids are the mainstay of treatment and can be used safely with proper precautions 2
• Never use high-potency or ultra-high-potency corticosteroids in infants due to dramatically increased risk of hypothalamic-pituitary-adrenal axis suppression from their high body surface area-to-volume ratio 1
• The basic principle is to use the least potent preparation required to keep the eczema under control 2

Environmental and Lifestyle Modifications

Avoid Provoking Factors

• Replace soaps and detergents with dispersible cream as a soap substitute since these remove natural lipid from already dry skin 2
• Avoid extremes of temperature 2
• Keep fingernails short to minimize scratching damage 2, 1
• Dress infants in cotton clothing next to skin and avoid wool or synthetic fabrics 2, 1

Second-Line Steroid-Sparing Options

Topical Calcineurin Inhibitors

• Pimecrolimus 1% cream is FDA-approved for infants as young as 3 months and is particularly useful for facial eczema 1, 3
• Tacrolimus 0.03% ointment is approved for children aged 2 years and above, valuable for face and genital regions 1
• These are especially important for sensitive areas where corticosteroid use carries higher risk of skin atrophy 1

Managing Complications

Secondary Bacterial Infection

• Watch for crusting, weeping, or worsening despite treatment—these indicate secondary bacterial infection, usually Staphylococcus aureus 2, 1
• Treat with flucloxacillin as first-choice antibiotic for S. aureus infections 1
• Avoid long-term topical antibiotics due to resistance and sensitization risk 1
• Continue topical corticosteroids during bacterial infection when appropriate systemic antibiotics are given concurrently 2

Eczema Herpeticum (Medical Emergency)

• Suspect herpes simplex infection if you observe grouped, punched-out erosions, vesiculation, or sudden deterioration 2, 1
• Treat with oral acyclovir early in the disease course 1
• Use intravenous acyclovir for ill, febrile patients 1

Adjunctive Measures for Pruritus

• Sedating antihistamines may help short-term for sleep disturbance caused by itching, primarily at night 1
• Non-sedating antihistamines have little value in atopic eczema 1

Critical Safety Considerations and Common Pitfalls

Corticosteroid Safety

• Provide only limited quantities of topical corticosteroids with specific instructions on safe application sites 1
• Monitor for skin atrophy, striae, or signs of systemic absorption 1
• Avoid abrupt discontinuation of corticosteroids to prevent rebound flares 1
• The risk of adverse effects increases with higher potency, occlusion, and prolonged use 2

Addressing Parental Concerns

• Lack of adherence to treatment often traces back to parents' fears of steroids—explain the different potencies and the benefits/risks clearly 2
• Education regarding application of topical preparations and quantity to use is essential 2
• Allow adequate time for explanation and discussion, and provide written information to reinforce issues discussed 2

Important Nuances

• While emollients are essential for maintenance, recent high-quality evidence shows that emollients alone during the first year of life probably do not prevent eczema development (RR 1.03,95% CI 0.81-1.31) and probably increase risk of skin infection (RR 1.34,95% CI 1.02-1.77) 4
• However, once eczema is established, emollients remain a cornerstone of treatment 2, 1
• Pimecrolimus use in infants 3-23 months showed increased incidence of pyrexia (32% vs. 13% vehicle), upper respiratory infections (24% vs. 14%), and nasopharyngitis (15% vs. 8%) in clinical trials 3