Treatment for Baby Eczema
Liberal and regular application of emollients combined with low-potency topical corticosteroids as needed forms the cornerstone of baby eczema treatment, with emollients applied at least twice daily after bathing and mild topical steroids used for active flare-ups. 1, 2
Essential First-Line Therapy: Emollients
- Apply emollients liberally and regularly (at least twice daily) to all affected areas, even when the skin appears clear - this provides a surface lipid film that retards evaporative water loss from the epidermis 3, 1, 2
- Apply emollients immediately after bathing when the skin is still slightly damp to maximize moisture retention 3, 1, 2
- Use a dispersible cream as a soap substitute for cleansing, as regular soaps and detergents strip natural lipids from already-dry skin 3, 2
- Regular bathing is beneficial for both cleansing and hydrating the skin in infants with eczema 3, 2
Important caveat: While emollients are essential for managing existing eczema, recent high-quality evidence shows that prophylactic emollient use in healthy newborns does NOT prevent eczema development and may actually increase risks of skin infections and possibly food allergy 4, 5. Therefore, only use emollients therapeutically once eczema is present, not preventively.
Topical Corticosteroids for Active Disease
- Use the least potent topical corticosteroid preparation that controls symptoms, applied no more than twice daily to affected areas 1, 2
- For infants, start with low-potency preparations (such as 1% hydrocortisone) and use with particular caution due to increased risk of systemic absorption 1, 6
- Hydrocortisone can be applied to affected areas 3-4 times daily in children 2 years and older, but requires physician consultation for children under 2 years 6
- Implement short "steroid holidays" when the eczema is controlled to minimize side effects including skin atrophy and pituitary-adrenal suppression 1, 2
- Do NOT withhold topical corticosteroids when secondary infection is present - continue them alongside appropriate systemic antibiotics 1
Managing Pruritus and Sleep Disruption
- Keep the infant's nails short to minimize damage from scratching 3, 2
- Use sedating antihistamines at nighttime as a short-term adjuvant during severe flares to help with sleep disruption through their sedative properties, not direct anti-pruritic effects 1, 2
- Non-sedating antihistamines have little to no value in atopic eczema and should not be used 1, 2
- Avoid irritant clothing such as wool; dress infants in cotton clothing which is more comfortable 3, 2
Managing Secondary Bacterial Infection
- Watch for signs of bacterial superinfection: increased crusting, weeping, or pustules 3, 1
- Prescribe oral flucloxacillin as first-line treatment for Staphylococcus aureus, the most common pathogen 1, 2
- Continue topical corticosteroids during bacterial infection when appropriate systemic antibiotics are given concurrently 1
Recognizing Eczema Herpeticum (Medical Emergency)
- If you observe grouped vesicles, punched-out erosions, or sudden deterioration with fever, suspect eczema herpeticum - this requires immediate treatment 3, 1
- Initiate oral acyclovir early in the disease course 1, 2
- In ill, feverish infants, administer acyclovir intravenously 1
Critical Pitfalls to Avoid
- Do not use emollients prophylactically in healthy newborns to "prevent" eczema - this approach has been definitively shown ineffective and may increase skin infections (RR 1.33) and possibly food allergy (RR 2.53) 4, 5
- Avoid very potent or potent corticosteroids in infants due to thin skin and high risk of systemic absorption and growth interference 1
- Do not use topical corticosteroids continuously without breaks - implement treatment holidays when disease is controlled 1, 2
- Parents often undertreated eczema due to steroid fears - take time to explain the different potencies and that low-potency steroids are safe when used appropriately 3, 1
- Avoid extremes of temperature in the infant's environment 3