What are the guidelines for using steroid creams in pediatric (peds) patients?

Topical Corticosteroid Use in Pediatric Patients

Critical Age-Specific Safety Considerations

Infants and young children (0-6 years) are uniquely vulnerable to hypothalamic-pituitary-adrenal (HPA) axis suppression due to their high body surface area-to-volume ratio and thinner, more absorptive skin compared to older children and adults. 1, 2, 3

High-Risk Population: Infants Under 2 Years

• Use only low-potency corticosteroids (Class V/VI/VII) such as hydrocortisone 1% or 2.5% cream in infants 1
• High-potency or ultra-high-potency topical corticosteroids should be avoided entirely in infants and young children 1, 2
• Children may absorb proportionally larger amounts of topical corticosteroids and are more susceptible to systemic toxicity including Cushing's syndrome, intracranial hypertension, linear growth retardation, and delayed weight gain 3

Potency Selection by Age and Body Site

General Potency Guidelines

For mild to moderate eczema in children, start with low-potency corticosteroids (hydrocortisone 1%), escalating to moderate-potency for inadequate response, and reserve potent corticosteroids for severe disease or short-term flare control (3-7 days). 2, 4

• Moderate-potency topical corticosteroids result in treatment success (cleared or marked improvement) in 52% versus 34% with mild-potency (OR 2.07) 5
• Potent topical corticosteroids result in treatment success in 70% versus 39% with mild-potency (OR 3.71) 5
• Evidence is uncertain for benefit of very potent over potent topical corticosteroids (OR 0.53,95% CI 0.13 to 2.09) 5

Site-Specific Recommendations

Face, neck, and skin folds: Use only Class V/VI corticosteroids (hydrocortisone 1% or 2.5%) to minimize risk of skin atrophy and telangiectasia 1, 2

Trunk and extremities: Mild to moderate potency corticosteroids based on severity 2

Diaper area: Avoid occlusive dressings; parents should not use tight-fitting diapers or plastic pants as these constitute occlusive dressings and increase systemic absorption 3

Application Frequency and Duration

Acute Flare Management

Apply topical corticosteroids once daily for potent preparations, as once-daily application is equally effective as twice-daily application (OR 0.97,95% CI 0.68 to 1.38). 5, 4

• Short bursts (3-7 days) of potent topical corticosteroids are as effective as prolonged use of milder preparations for controlling flares 2, 6, 4
• Apply as a thin film to affected areas 2
• Maximum duration: up to 3 weeks for super-high-potency, up to 12 weeks for high- or medium-potency, no specified limit for low-potency 4

Maintenance and Relapse Prevention

For children with recurrent eczema, weekend (proactive) therapy with topical corticosteroids reduces relapse from 58% to 25% (RR 0.43,95% CI 0.32 to 0.57) compared to reactive use only. 5

• After initial 2-week control phase, apply topical corticosteroids on weekends and topical vitamin D analogue (calcitriol) on weekdays 7
• This rotational approach serves as a steroid-sparing strategy 1

Special Considerations for Psoriasis in Children

Localized Psoriasis (Ages 12+)

For children ≥12 years with mild-moderate plaque psoriasis, use calcipotriol/betamethasone dipropionate combination once daily for up to 4 weeks. 1

• 58% of pediatric patients (12-17 years) achieved scalp clearance after 8 weeks with calcipotriol/betamethasone suspension 1
• Monitor vitamin D metabolites when applying to large body surface areas 1

Sensitive Areas (Face and Genitals)

For facial and genital psoriasis in children, use tacrolimus 0.1% ointment as off-label monotherapy rather than topical corticosteroids. 7, 1

• 88% of children achieved clearance or excellent improvement within 30 days with tacrolimus for facial or inverse psoriasis 1
• This avoids corticosteroid-related atrophy risk in sensitive areas 1, 2

Prescribing and Monitoring

Quantity and Instructions

Prescribe limited quantities with explicit written instructions on amount, application sites, and duration to prevent overuse. 1, 3

• Use fingertip unit method: one fingertip unit (from tip of index finger to distal interphalangeal joint crease) covers approximately 2% body surface area in adults 4
• Provide careful instruction to caregivers on safe application sites 2

Monitoring Requirements

For children requiring long-term topical corticosteroid therapy, assess growth parameters and monitor for signs of HPA axis suppression. 1, 3

• Consider urinary free cortisol test and ACTH stimulation test when using potent steroids over large surface areas or with occlusion 3
• Monitor for local adverse effects: skin atrophy, striae, telangiectasia (especially on face with >20g over 6 months) 4, 8
• Regular dermatologist follow-up is essential 1

Critical Pitfalls to Avoid

Abrupt discontinuation: Even low-potency steroids can cause rebound flares when stopped suddenly; taper gradually or transition to maintenance regimen 1, 3

Occlusion in infants: Avoid occlusive dressings, tight-fitting diapers, or plastic pants which dramatically increase systemic absorption 3

Prolonged high-potency use: Limit ultra-high-potency topical corticosteroids to short-term treatment of localized disease only 7

Face and fold treatment: Never use high-potency corticosteroids on face, neck, or intertriginous areas due to increased absorption and atrophy risk 2, 4

Adjunctive Therapies

Regular emollient use has both short- and long-term steroid-sparing effects and should be used liberally alongside topical corticosteroids. 2, 5

• Emollients may be applied at the same time or different times of day with calcipotriene to reduce irritation 1
• For severe itching episodes, sedating antihistamines may be useful as short-term adjuncts, particularly at night 2
• Wet-wrap therapy with topical corticosteroids is effective for moderate to severe eczema as short-term second-line treatment 2

Adverse Event Profile

In trials assessing flare treatment strategies, abnormal skin thinning occurred in only 1% of participants (26/2266), with most cases from higher-potency preparations (16 very potent, 6 potent, 2 moderate, 2 mild). 5

• Telangiectasia on cheeks increases with longer disease duration and application of >20g to face over 6 months 8
• Steroid-induced atrophy of antecubital and popliteal fossae more common in males 8
• In weekend (proactive) therapy trials, no cases of abnormal skin thinning were identified in 1050 participants at end of treatment 5