Treatment of Pediatric Contact Dermatitis
For pediatric contact dermatitis, use low to medium potency topical corticosteroids as first-line therapy, applied once to twice daily for 1-2 weeks, with potency selection based on the child's age, affected body site, and severity of inflammation. 1
Initial Treatment Strategy
Topical Corticosteroid Selection by Age and Location
For children ages 0-6 years: Use lower potency formulations due to their high body surface area-to-volume ratio, which increases risk of hypothalamic-pituitary-adrenal (HPA) axis suppression 1, 2
For trunk and extremities: Apply low to medium potency topical corticosteroids once to twice daily for 1-2 weeks depending on response 1
For face, neck, and skin folds: Never use ultra-high-potency corticosteroids in these areas due to high risk of skin atrophy 1
For children under 2 years: Over-the-counter hydrocortisone can be used, but consult a physician first 3
Critical Safety Parameters
Limit high-potency corticosteroid use to ≤2 weeks to prevent HPA axis suppression, especially in young children 1, 2
Monitor for systemic absorption signs: Children absorb proportionally larger amounts of topical corticosteroids than adults, making them more susceptible to systemic toxicity including growth retardation, delayed weight gain, and low plasma cortisol levels 2
Avoid occlusive dressings unless specifically directed, as they augment systemic absorption; parents should not use tight-fitting diapers or plastic pants in the diaper area during treatment 2
Essential Adjunctive Measures
Barrier Restoration and Symptom Control
Apply emollients liberally and frequently to restore skin barrier function throughout the treatment course 1
Use oral antihistamines as adjunctive therapy for pruritus control, particularly helpful at bedtime to reduce nocturnal scratching 1
Implement allergen avoidance as the cornerstone of management once the causative agent is identified through patch testing 4, 5
Diagnostic Considerations
Perform patch testing in children with persistent eczematous eruptions, particularly those with hand and eyelid eczema, as allergic contact dermatitis in children is increasing 4
Common pediatric allergens include: nickel, topical antibiotics, preservative chemicals, fragrances, and rubber accelerators 4
What to Avoid
Contraindicated or Discouraged Practices
Do not use oral corticosteroids routinely in pediatric plant contact dermatitis or mild-to-moderate contact dermatitis 1
Avoid topical antibiotics routinely, as they increase resistance and sensitization risk 1, 6
Do not use barrier creams as primary protection, as they confer a false sense of security and are of questionable value in protecting against irritants 4
Severe or Refractory Cases
Second-Line Options
For severe cases resistant to topical therapy: Consider wet-wrap therapy with topical corticosteroids for 3-7 days (possibly extending to 14 days in severe cases) 6
For facial and intertriginous areas: Topical calcineurin inhibitors (tacrolimus 0.03% ointment or pimecrolimus 1% cream) are preferred in children aged 2 years and above to avoid skin atrophy 6
For extensive involvement: If allergic contact dermatitis involves greater than 20% body surface area, systemic steroid therapy may be required, with oral prednisone tapered over 2-3 weeks to prevent rebound dermatitis 7
Common Pitfalls to Avoid
Inadequate treatment duration: Rapid discontinuation of steroids in severe cases can cause rebound dermatitis; ensure proper tapering when systemic steroids are used 7
Overlooking allergen identification: Without identifying and avoiding the causative allergen, contact dermatitis often has a poor long-term prognosis with only 25% complete healing in occupational cases 4
Underestimating absorption in children: Pediatric patients demonstrate greater susceptibility to HPA axis suppression due to larger skin surface area to body weight ratio 2