What is the recommended treatment plan for pediatric eczema?

Pediatric Eczema Treatment Plan

Foundation: Emollients and Basic Skin Care

All children with eczema, regardless of severity, should receive liberal emollient application at least twice daily (200-400g per week) plus avoidance of triggers as the cornerstone of management. 1, 2

• Apply fragrance-free emollients liberally and frequently—at least twice daily and as needed throughout the day to maintain barrier function 2
• Ointments and creams are preferred for very dry skin or winter use, applied immediately after a 10-15 minute lukewarm bath when skin is most hydrated 1, 2
• Regular emollient use has both short-term and long-term steroid-sparing effects 1, 3
• Educate families on trigger avoidance including allergens, scratching, environmental irritants, weather conditions, infections, and stress 1

Stepwise Treatment by Severity

Mild Eczema

Use reactive therapy with low-potency topical corticosteroids (hydrocortisone 1%) applied once or twice daily to affected areas until lesions significantly improve. 1, 2, 3

• Hydrocortisone 1% is the only appropriate corticosteroid potency for infants and young children 2, 3
• Alternative options include pimecrolimus 1% cream (FDA-approved for infants ≥3 months) or crisaborole (PDE-4 inhibitor, approved ≥3 months) 1, 2
• Pimecrolimus is particularly useful for facial eczema as a steroid-sparing alternative 2

Moderate Eczema

Use proactive and reactive therapy with low to medium potency topical corticosteroids (fluticasone or mometasone) applied once or twice daily during flares, then transition to twice-weekly maintenance on previously affected areas. 1, 4

• Apply daily to active lesions for 3-7 days or until significant improvement, then switch to proactive twice-weekly application to prevent relapses 1, 4
• This proactive approach can be continued for up to 16 weeks and reduces flare frequency 1, 4
• Alternative options include tacrolimus 0.03% ointment (approved ≥2 years) or pimecrolimus for steroid-sparing maintenance 1, 2
• Consider wet-wrap therapy for 3-7 days (maximum 14 days) as second-line treatment if conventional topical therapy fails 1

Severe to Very Severe Eczema

Use medium to high potency topical corticosteroids for short periods (3-7 days maximum) on the body, with add-on systemic therapies for refractory cases. 1, 3

• Add-on options include cyclosporine, methotrexate, azathioprine (off-label), dupilumab (approved ≥6 years in Taiwan), short-course oral corticosteroids (<7 days), or phototherapy (not recommended <12 years) 1
• Wet-wrap therapy with topical corticosteroids is an effective short-term option before escalating to systemic immunosuppressants 1

Critical Safety Considerations by Age

Infants and Young Children (0-6 years)

Never use high-potency or ultra-high-potency corticosteroids in infants—risk of hypothalamic-pituitary-adrenal (HPA) axis suppression is significantly elevated due to high body surface area-to-volume ratio. 2, 3, 5

• Infants and young children are more susceptible to systemic toxicity from topical corticosteroids, including HPA axis suppression, Cushing's syndrome, linear growth retardation, and delayed weight gain 5, 6
• Provide only limited quantities with specific instructions on safe application sites 2
• Monitor for skin atrophy, striae, or signs of systemic absorption 2, 4

Adolescents (≥12 years)

• Adolescents have lower risk of HPA axis suppression than younger children, but high or ultra-high potency steroids should still be avoided or used only for short periods in severe cases 4
• Clobetasol propionate is not recommended for patients under 12 years of age 6

Location-Specific Guidance

Use only low-potency corticosteroids (hydrocortisone 1%) on the face, neck, and skin folds to avoid skin atrophy, or consider topical calcineurin inhibitors as alternatives. 1, 3, 4

• Tacrolimus 0.03% and pimecrolimus 1% are particularly valuable for sensitive areas including face and genital regions 3, 4
• Low to medium potency corticosteroids can be used for longer periods on trunk and extremities 1

Managing Complications

Bacterial Superinfection

Watch for crusting, weeping, or worsening despite treatment—these indicate secondary bacterial infection (usually Staphylococcus aureus) requiring oral antibiotics. 2, 3

• Flucloxacillin is the first-choice antibiotic for S. aureus infections 2, 4
• Erythromycin may be used for penicillin-allergic patients 3
• Avoid long-term topical antibiotics due to resistance and sensitization risk 2

Viral Infections

• Eczema herpeticum (herpes simplex infection) requires prompt treatment with oral acyclovir 2, 3
• Use intravenous acyclovir for ill, febrile patients 3

Adjunctive Therapies

• Sedating antihistamines may help short-term for sleep disturbance caused by itching, primarily at night 1, 2, 3
• Non-sedating antihistamines have little value in atopic eczema 2, 3
• Use cotton clothing next to skin and avoid wool or synthetic fabrics 2
• Keep fingernails short to minimize scratching damage 2

Common Pitfalls to Avoid

Do not continue daily corticosteroid application beyond 7 days without reassessment—transition to proactive twice-weekly maintenance instead of abrupt discontinuation to prevent rebound flares. 4

• Avoid using high-potency or ultra-high-potency steroids as first-line for moderate disease 4
• Do not use potent steroids on face, neck, or intertriginous areas 4
• Consider poor treatment adherence or alternative diagnoses if treatment response is inadequate 1
• Treatment should not be applied more than twice daily 3

Adverse Events to Monitor

Skin care interventions, particularly emollients, probably increase risk of skin infection (RR 1.34) and may increase risk of infant slippage or stinging/allergic reactions. 7

• Monitor for increased skin infections during emollient use, particularly in the first year of life 7
• Be aware that emollient use may be associated with a possible increase in food allergy, though evidence is uncertain 8, 7