What is the initial treatment for pediatric eczema?

Initial Treatment for Pediatric Eczema

The initial treatment for pediatric eczema consists of regular emollient application combined with mild to moderate potency topical corticosteroids applied once or twice daily to active lesions, with emollients serving as the foundation of therapy regardless of disease severity. 1, 2

Foundation: Emollient Therapy

• Liberal, frequent emollient use is essential and should be applied to all skin, not just affected areas, preferably immediately after a 10-15 minute lukewarm bath when skin is still damp 1, 2
• Regular emollient use provides both short-term and long-term steroid-sparing effects in mild to moderate eczema 1, 3
• Fragrance-free formulations are preferred to minimize irritation 1
• Ointments provide maximum occlusive effect and penetration; creams are water-based and less greasy; both are suitable for very dry skin 1

Topical Corticosteroids for Active Lesions

Potency Selection Based on Age and Severity

• For infants and young children (under 2 years): Use only mild potency corticosteroids (hydrocortisone 1%) due to their high body surface area-to-volume ratio, which increases risk of systemic absorption and HPA axis suppression 2, 3
• For children 2 years and older with mild eczema: Use low-potency corticosteroids (hydrocortisone 1%) 3
• For moderate eczema: Use low to medium potency corticosteroids 1, 3
• For severe eczema: Use medium to high potency corticosteroids for short periods (3-7 days only) 3, 4

Application Guidelines

• Apply once or twice daily to active lesions until significantly improved—applying more than twice daily provides no additional benefit 1, 2, 3
• Potent and moderate potency corticosteroids are more effective than mild preparations for moderate to severe eczema, but once daily application is as effective as twice daily for potent corticosteroids 5
• The order of application (emollient first vs. corticosteroid first) does not matter—parents can apply in whichever order they prefer, with a 15-minute interval if desired 6

Site-Specific Considerations

• Face, neck, and skin folds: Use only low-potency corticosteroids to avoid skin atrophy 1, 3
• Body and limbs: Low to medium potency based on severity 1, 3
• Avoid high-potency or ultra-high-potency corticosteroids in infants and young children 2, 3

Alternative for Sensitive Areas (Age 2+ Years)

• Topical calcineurin inhibitors (tacrolimus 0.03% ointment or pimecrolimus 1% cream) are effective steroid-sparing alternatives for sensitive areas such as face and genital regions 1, 2, 3
• Pimecrolimus is FDA-approved for children as young as 3 months, though the American Academy of Dermatology and other guidelines recommend use starting at age 2 years 2, 7
• Tacrolimus 0.03% applied once or twice daily is significantly more efficacious than 1% hydrocortisone acetate in moderate to severe eczema, with twice daily application providing greatest benefit 8
• Transient mild to moderate skin burning occurs more frequently with tacrolimus but typically resolves within 3-4 days 8

Adjunctive Measures

• Keep fingernails short to minimize damage from scratching 2
• Avoid irritants including soaps, detergents, and wool clothing; cotton clothing is preferred 2
• Sedating antihistamines may be useful as short-term adjuncts during severe nighttime itching episodes, but non-sedating antihistamines have little value 2, 3

Safety Considerations and Monitoring

• The risk of adverse effects increases with higher potency, occlusion, and prolonged use 2, 3
• Abnormal skin thinning is rare (approximately 1% in trials) but increases with higher potency corticosteroids 5
• Provide clear instructions to caregivers on amount to apply, safe application sites, and duration of treatment 2, 3
• Avoid abrupt discontinuation of high-potency corticosteroids to prevent rebound flares 2
• Monitor for signs of skin atrophy, striae, or systemic absorption 3

Managing Complications

• Secondary bacterial infections (usually Staphylococcus aureus) require antibiotic treatment with flucloxacillin as first choice; erythromycin for penicillin-allergic patients 2, 3
• Eczema herpeticum (herpes simplex infection) requires prompt treatment with oral acyclovir; use intravenous acyclovir for ill, febrile patients 2, 3

Common Pitfalls to Avoid

• Do not use high or very potent corticosteroids as initial therapy in children, especially infants, due to increased risk of HPA axis suppression 2, 3
• Short bursts (3 days) of potent corticosteroids are as effective as prolonged use (7 days) of mild preparations for mild to moderate eczema, avoiding the misconception that longer is always better 9
• Do not delay emollient therapy while waiting for corticosteroid prescription—emollients should begin immediately 1
• Topical corticosteroids are not indicated for conditions like pityriasis alba or perioral dermatitis where they may not be useful or could worsen the condition 4