What is the recommended treatment for pediatric dermatitis?

Treatment for Pediatric Dermatitis

For pediatric dermatitis (atopic dermatitis), initiate treatment with liberal emollient use throughout the day combined with low-potency topical corticosteroids (hydrocortisone 1%) applied once or twice daily to affected areas for the shortest duration necessary to control symptoms. 1

Foundational Therapy (All Ages)

• Apply emollients liberally and frequently throughout the day, immediately after bathing to lock in moisture 2, 1
• Regular emollient use provides both short-term and long-term steroid-sparing effects in mild to moderate dermatitis 2
• Use soap-free cleansers or dispersible cream as soap substitutes during bathing to avoid stripping natural lipids 1
• Continue emollient use even when skin appears clear to maintain barrier function 2, 1

Topical Corticosteroid Selection by Disease Severity

Mild Dermatitis

• Use low-potency corticosteroids (hydrocortisone 1%) applied 3-4 times daily maximum to affected areas 1
• Apply only to active lesions, not normal-appearing skin 2

Moderate Dermatitis

• Use low-to-medium potency corticosteroids applied once or twice daily 2, 1
• Treatment duration should be limited to the shortest period necessary, typically 3-7 days 3
• For moderate-to-severe cases, consider proactive therapy with twice-weekly application of low-to-medium potency corticosteroids (fluticasone or mometasone) to previously affected areas for up to 16 weeks to prevent relapses 2

Severe Dermatitis

• Wet-wrap therapy with topical corticosteroids is recommended as second-line treatment for 3-7 days, with possible extension to 14 days in severe cases 2
• This approach is effective before escalating to systemic immunosuppressive therapies 2

Critical Age-Specific Safety Considerations

Children ages 0-6 years are at significantly elevated risk for hypothalamic-pituitary-adrenal (HPA) axis suppression due to their high body surface area-to-volume ratio. 2, 1

• High-potency or ultra-high-potency topical corticosteroids should be avoided or used only with extreme caution and close dermatologic supervision in this age group 2, 1
• Infants and young children should be treated with less potent corticosteroids than older children and adults 2
• Provide careful instruction to caregivers on the amount to apply and safe sites for use, and supply limited quantities 2
• Be aware of potential rebound flare if high-potency corticosteroids are abruptly discontinued without transitioning to alternative treatment 2

Site-Specific Treatment Approach

Face, Neck, and Skin Folds

• Use only low-potency corticosteroids (hydrocortisone 1%) on sensitive areas to avoid skin atrophy 2, 1
• Duration of exposure to potent corticosteroids in these areas should be strictly limited 2
• Tacrolimus 0.03% ointment is an effective steroid-sparing alternative for facial and genital dermatitis, showing clearance or excellent improvement within 30 days in pediatric patients 2, 1

Trunk and Extremities

• Low-to-medium potency corticosteroids can be used for longer periods on these areas 2

Steroid-Sparing Alternatives

Topical Calcineurin Inhibitors (TCIs)

• Pimecrolimus 1% cream and tacrolimus ointment (0.03% for ages 2-15 years, 0.1% for ages 16+) are steroid-sparing immunomodulators approved for patients aged 2 years and older 2, 4
• Pimecrolimus is indicated as second-line therapy for mild-to-moderate atopic dermatitis in patients who have failed to respond adequately to other topical treatments or when those treatments are not advisable 4
• Pimecrolimus may be used in infants as young as 3 months, though this is off-label 5
• TCIs are particularly useful for face, genitalia, and body folds where corticosteroid side effects are more concerning 2
• Most common adverse effects are burning and stinging at application site 2
• Proactive therapy with twice-weekly TCI application to previously affected areas may prevent relapses in moderate-to-severe cases 2

Topical PDE-4 Inhibitors

• Crisaborole ointment is approved for mild-to-moderate atopic dermatitis in patients aged 3 months and above 2
• Serves as an alternative to topical corticosteroids or calcineurin inhibitors 2
• Most common adverse effect is stinging or burning at application site 2

Adjunctive Treatments

• Oral antihistamines are recommended as adjuvant therapy for reducing pruritus, particularly sedating antihistamines for nighttime use during severe itching episodes 2, 1
• Keep nails short to minimize skin damage from scratching 1
• For moderate-to-severe dermatitis with clinical signs of secondary bacterial infection, intranasal mupirocin and bleach baths may reduce disease severity 2
• Long-term application of topical antibiotics is not recommended due to increased risk of resistance and sensitization 2

Systemic Therapy for Refractory Cases

Children Ages 6 Years and Older

• Dupilumab is recommended for severe-to-very-severe atopic dermatitis refractory to conventional topical treatment 2

Very Severe Cases (All Ages)

• Immunomodulators including cyclosporine, azathioprine, and methotrexate may be used, adjusted to minimal effective dose once response is attained 2
• Long-term use of oral corticosteroids is not recommended due to unfavorable risk-benefit profile and risk of rebound flares 2, 3
• Short-term use (<7 days) of oral corticosteroids may be considered only when clinically necessary 2

Phototherapy

• Phototherapy is not recommended for children younger than 12 years as the long-term safety profile remains unclear 2

Common Pitfalls to Avoid

• Never apply topical corticosteroids more than twice daily—this does not improve efficacy and increases adverse effects 1
• Avoid using high-potency corticosteroids in young children without close dermatologic supervision due to significantly elevated HPA suppression risk 2, 1
• Do not use topical antihistamines routinely, as they may increase risk of contact dermatitis and have insufficient evidence for efficacy 2
• Avoid combining immunomodulators with phototherapy 2
• Do not use systemic antibiotics unless there is clinical evidence of bacterial infection while on standard treatment 2