What are the causes and management of erythema (redness) of the cheek in children?

Red Cheek in Children: Causes and Management

Most Likely Diagnosis

Atopic dermatitis is the primary consideration when facial redness affects children under 4 years, as it characteristically involves the cheeks or forehead in this age group. 1

Differential Diagnosis by Clinical Pattern

Classic "Slapped Cheek" Appearance

• Erythema infectiosum (Fifth disease): Viral prodrome followed by bright red facial rash with circumoral pallor 2
• Associated with pruritus and typically self-limited 2

Eczematous Red Cheeks (Most Common)

• Atopic dermatitis: Requires itchy skin condition plus three or more of: history of itchiness in skin creases or cheeks, personal or family history of atopy, general dry skin in past year, visible flexural eczema or facial involvement, onset in first two years of life 1
• Characterized by dry skin (xerosis) progressing to inflammatory changes with potential fissures 3

Other Important Causes

• Impetigo: Superficial bacterial infection most commonly affecting face and extremities, with honey-colored crusting 2, 4
• Scarlet fever: Rash develops on upper trunk then spreads, typically sparing palms and soles, associated with fever 2
• Cellulitis: Deep spreading infection requiring urgent treatment 4

Critical Red Flags Requiring Immediate Action

Eczema Herpeticum (Medical Emergency)

• Multiple uniform "punched-out" erosions or vesiculopustular eruptions that are very similar in shape and size 5
• Immediate systemic acyclovir plus empirical antibiotics (cephalexin or flucloxacillin) to cover secondary bacterial infection 5, 1
• May progress rapidly to systemic infection without antiviral therapy 5

Severe Bacterial Superinfection

• Extensive crusting, weeping, or honey-colored discharge indicates Staphylococcus aureus infection 1
• Requires flucloxacillin (or erythromycin if penicillin allergy) 6, 1

Spreading Infection

• Cellulitis or erysipelas with spreading borders requires urgent systemic antibiotics 4
• Sequelae can be life-threatening if treatment delayed 4

First-Line Management Algorithm for Atopic Dermatitis

Step 1: Emollient Therapy (Foundation)

• Apply emollients liberally and frequently (at least twice daily) to all affected areas, ideally after bathing 1, 3
• Use dispersible cream as soap substitute instead of regular soaps and detergents, which remove natural lipids and worsen dry skin 1, 3
• Avoid hot showers and excessive soap use 3

Step 2: Topical Corticosteroids

• Use topical corticosteroids as mainstay of treatment, selecting the least potent preparation required to control the eczema 3
• Apply no more than twice daily 6
• Use with caution in very potent and potent categories for limited periods only to avoid pituitary-adrenal suppression 6

Step 3: Adjunctive Measures

• Keep nails short to minimize damage from scratching 1
• Avoid irritant clothing such as wool next to skin and avoid temperature extremes 1
• Short-term sedating antihistamines (not non-sedating types) for severe pruritus during relapses, particularly at night 6

Step 4: Treat Secondary Infection

• Do not overlook secondary bacterial infection, which commonly complicates eczema 3
• Flucloxacillin for S. aureus (most common pathogen) 6, 3
• Phenoxymethylpenicillin if β-hemolytic streptococci isolated 6
• Erythromycin for penicillin allergy or flucloxacillin resistance 6

Special Considerations for Children Under 7 Years

For children under 7 years with mild-to-moderate ocular symptoms or any eye involvement on dupilumab therapy, commence preservative-free ocular lubricants and refer to ophthalmology within 4 weeks 6 (Note: This applies specifically to children on dupilumab for atopic dermatitis)

Education and Follow-Up

• Allow adequate time for explanation with parents, demonstrating how to apply treatments and providing written information 1
• Education regarding application technique and quantity to use is essential 1
• Reassess in 1-2 weeks if no improvement occurs with initial therapy 1
• Failure to respond to first-line treatment is indication for specialist referral 6

Common Pitfalls to Avoid

• Missing eczema herpeticum: Look for uniform punched-out lesions rather than typical eczema morphology 5
• Undertreating secondary bacterial infection: Crusting and weeping indicate bacterial superinfection requiring antibiotics 3
• Overusing potent topical steroids: Risk of pituitary-adrenal suppression and growth interference in children 6
• Prescribing non-sedating antihistamines: These have little to no value in atopic eczema; only sedating types help with pruritus 6
• Using regular soaps: These strip natural lipids and worsen the condition 1, 3