What is the recommended treatment for pediatric eczema?

Recommended Treatment for Pediatric Eczema

For pediatric eczema, begin with liberal and frequent emollient application as foundational therapy, then add low-to-medium potency topical corticosteroids (hydrocortisone 1-2.5% for mild disease, or medium potency for moderate disease) applied once or twice daily to affected areas, with topical calcineurin inhibitors (tacrolimus 0.03% or pimecrolimus 1%) reserved as steroid-sparing alternatives particularly for sensitive areas like the face and neck. 1, 2

Foundational Therapy: Emollients and Skin Care

• Apply emollients liberally and frequently throughout the day to provide both short-term symptom relief and long-term steroid-sparing effects 2
• Use soap-free cleansers or dispersible cream as soap substitutes during bathing to avoid removing natural lipids 3, 2
• Apply emollients immediately after bathing to retain moisture in the skin 2
• Continue regular emollient use even when skin appears clear to prevent relapses 3, 2

Topical Corticosteroid Selection by Disease Severity

Mild Eczema

• Use low-potency corticosteroids (hydrocortisone 1%) applied to affected areas 1-2 times daily 2
• Treatment should not be applied more than twice daily, as this does not improve efficacy and increases adverse effects 3, 2

Moderate Eczema

• Use low-to-medium potency corticosteroids applied once or twice daily 2
• Moderate-potency topical corticosteroids result in significantly more patients achieving treatment success compared to mild-potency agents (52% vs 34% clearance rates) 4
• Once daily application of potent topical corticosteroids is as effective as twice daily application 4

Severe Eczema

• Potent topical corticosteroids result in large increases in treatment success (70% vs 39% compared to mild potency) 4
• Consider referral to dermatology for second-line therapies including phototherapy (narrowband UVB for children ≥12 years), systemic immunomodulators, or biologics 3

Critical Age-Specific Safety Considerations

Infants and Young Children (0-6 years)

• This age group is particularly vulnerable to hypothalamic-pituitary-adrenal (HPA) axis suppression due to high body surface area-to-volume ratio 1, 2, 5
• Limit treatment to Class V/VI/VII corticosteroids only (hydrocortisone 1% or 2.5%) 1
• High-potency or ultra-high-potency topical corticosteroids should be avoided entirely in this age group 1, 2
• Prescribe limited quantities with explicit instructions on amount and application sites to prevent overuse 1
• Assess growth parameters in infants requiring long-term topical corticosteroid therapy 1

Site-Specific Treatment Approach

Sensitive Areas (Face, Neck, Skin Folds, Genitals)

• Use only low-potency corticosteroids (hydrocortisone 1%) on the face, neck, and skin folds to avoid skin atrophy 2
• Tacrolimus 0.03% ointment is highly effective for facial and genital eczema, showing excellent improvement within 30 days in 88% of pediatric patients 3, 2
• Complete clearance of facial eczema was achieved within 72 hours with tacrolimus 0.1% in case series 1

Body and Extremities

• Medium-to-potent topency corticosteroids can be used on trunk and extremities for moderate-to-severe disease 3, 2
• Limit duration to the shortest period necessary to achieve symptom control 2

Topical Calcineurin Inhibitors as Steroid-Sparing Alternatives

Tacrolimus 0.03% Ointment

• Significantly more efficacious than 1% hydrocortisone acetate in moderate-to-severe pediatric eczema (76.7% vs 47.6% median improvement in disease severity with twice daily application) 6
• Approved for children aged 2 years and above 3
• Particularly effective for severe baseline disease when applied twice daily 6
• Most common adverse effect is transient mild-to-moderate skin burning that resolves within 3-4 days 6

Pimecrolimus 1% Cream

• FDA-approved for children aged 3 months and above with mild-to-moderate atopic dermatitis 7
• In clinical trials, 35% of patients treated with pimecrolimus were clear or almost clear compared to 18% with vehicle 7
• Significant treatment effect seen by day 15, with improvement in erythema and infiltration by day 8 7
• Do not use in children under 2 years old per FDA black box warning 7
• Use only for short periods with breaks in between; stop when symptoms resolve 7

Maintenance Therapy to Prevent Relapses

• For moderate-to-severe eczema, apply topical corticosteroids twice weekly to previously affected areas (proactive/weekend therapy) to prevent relapses 2, 4
• Weekend proactive therapy results in large decrease in likelihood of relapse from 58% to 25% 4
• Continue regular emollient use as maintenance even when skin appears clear 3, 2

Adjunctive Treatments

Antihistamines

• Sedating antihistamines are useful as short-term adjuncts during severe pruritus episodes, particularly at night 3, 2
• Their therapeutic value resides principally in sedative properties rather than antihistamine effects 3
• Non-sedating antihistamines have little or no value in atopic eczema 3
• Large doses may be required in children 3

Infection Management

• Flucloxacillin is the most appropriate antibiotic for treating secondary Staphylococcus aureus infection, the commonest pathogen 3
• Phenoxymethylpenicillin should be given if beta-hemolytic streptococci are isolated 3
• Erythromycin may be used with flucloxacillin resistance or penicillin allergy 3
• Eczema herpeticum responds to oral acyclovir; give early in disease course, or intravenously if patient is ill and febrile 3

Common Pitfalls to Avoid

• Do not apply topical corticosteroids more than twice daily - this does not improve efficacy and increases adverse effects 3, 2
• Avoid abrupt discontinuation of topical corticosteroids - this can cause rebound flares, particularly with higher potency agents 1
• Do not use high-potency corticosteroids in young children without close dermatologic supervision - risk of HPA suppression is significantly elevated 1, 2
• Do not cover treated skin with bandages, dressings, or wraps (normal clothing is acceptable) 7
• Avoid sun exposure, tanning beds, or UV light therapy while using topical calcineurin inhibitors 7

Application Technique

• Wash hands before applying treatment 7
• Ensure skin is dry after bathing before application 7
• Apply thin layer only to affected areas 7
• The order of application (emollient first vs. corticosteroid first) does not matter - parents can apply in whichever order they prefer 8
• If using moisturizers with topical calcineurin inhibitors, apply moisturizer after the medication 7
• Caregivers should wash hands after application unless treating their own hands 7

When to Refer to Specialist

• Failure to respond to first-line treatment after 6 weeks 3, 2, 7
• Need for second-line therapies (phototherapy, systemic immunomodulators, biologics) 3
• Consideration of systemic corticosteroids, which should never be taken lightly and not used for maintenance 3
• Maximum waiting time for first specialist appointment should be 6 weeks 3