What is the recommended treatment approach for children with eczema?

Treatment of Eczema in Children

The cornerstone of eczema management in children is liberal application of emollients at least twice daily combined with the least potent topical corticosteroid effective for controlling flares, with hydrocortisone 1% as first-line for mild disease and moderate-potency steroids for more severe presentations. 1, 2

First-Line Treatment Strategy

Emollients as Foundation

• Apply emollients liberally and frequently—at least twice daily and as needed throughout the day to maintain skin barrier function 1, 3
• Apply immediately after bathing when skin is still damp to lock in moisture 1, 3
• Ointments and creams are preferred for very dry skin 3
• Regular emollient use has both short and long-term steroid-sparing effects 2

Bathing Technique

• Use lukewarm water for 5-10 minutes to prevent excessive drying 1
• Replace soaps with gentle, dispersible cream cleansers as soap substitutes 1
• Bathing is beneficial for both cleansing and hydrating the skin 1

Topical Corticosteroid Selection by Severity

• Mild eczema: Hydrocortisone 1% (low-potency) 2, 3
• Moderate eczema: Low to medium-potency corticosteroids 2
• Severe eczema: Medium to high-potency corticosteroids for short periods (3-7 days only) 2
• Apply once or twice daily to affected areas until lesions significantly improve 3

Moderate-potency topical corticosteroids result in treatment success (cleared or marked improvement) in 52% versus 34% with mild-potency (OR 2.07), and potent corticosteroids achieve 70% versus 39% success compared to mild-potency (OR 3.71). 4

Application Frequency

• Once daily application of potent topical corticosteroids is as effective as twice daily application (OR 0.97) 4
• Treatment should not be applied more than twice daily 5

Critical Safety Considerations by Age

For infants under 2 years:

• Use only hydrocortisone 1% (low-potency) 3
• Never use high-potency or ultra-high-potency corticosteroids in infants due to their high body surface area-to-volume ratio, which significantly increases risk of hypothalamic-pituitary-adrenal axis suppression 2, 3
• Pimecrolimus 1% cream is FDA-approved for infants as young as 3 months as a steroid-sparing alternative, particularly for facial eczema 3, 6

For children 2 years and older:

• Use only low-potency corticosteroids for sensitive areas (face, neck, skin folds) to avoid skin atrophy 2
• Tacrolimus 0.03% ointment is approved for children aged 2+ years as a steroid-sparing alternative for face and genital regions 2, 3
• Provide only limited quantities of topical corticosteroids with specific instructions on safe application sites 3

Preventing Relapses: Proactive Therapy

Weekend (proactive) therapy with twice-weekly application of topical corticosteroids to previously affected areas dramatically reduces relapse rates from 58% to 25% (RR 0.43) in moderate to severe eczema. 4

• Apply topical corticosteroids twice weekly to previously affected areas for 16-20 weeks 4
• This approach is particularly effective for moderate to severe eczema 2, 4

Managing Complications

Secondary Bacterial Infection

• Watch for crusting, weeping, or worsening despite treatment 1, 3
• Flucloxacillin is the first-choice antibiotic for Staphylococcus aureus infections 5, 1, 2
• Erythromycin may be used for penicillin-allergic patients 5, 2
• Avoid long-term topical antibiotics due to resistance and sensitization risk 3

Eczema Herpeticum (Herpes Simplex Infection)

• Requires prompt treatment with oral acyclovir 5, 1, 2
• Use intravenous acyclovir for ill, febrile patients 5, 2

Adjunctive Measures

Pruritus Management

• Sedating antihistamines may help short-term for sleep disturbance, primarily at night 1, 2, 3
• Large doses may be required in children 5
• Non-sedating antihistamines have little value in atopic eczema 1, 2

Trigger Avoidance

• Use cotton clothing next to skin and avoid wool or synthetic fabrics 1, 2, 3
• Keep fingernails short to minimize scratching damage 1, 2, 3
• Maintain comfortable room temperatures, avoiding excessive heat 1
• Avoid harsh detergents and fabric softeners 1

Application Technique Details

• The order of application (emollient first versus corticosteroid first) does not affect treatment outcomes 7
• Apply emollients after topical corticosteroids if using both 2
• Wait 15 minutes between applications if preferred, though not required 7
• Do not apply treatments more than twice daily 5
• Stop topical corticosteroids when signs and symptoms resolve or as directed 6

Common Pitfalls to Avoid

• Avoid prolonged continuous use of topical corticosteroids to prevent side effects including skin atrophy, striae, and HPA axis suppression 1, 2, 3
• Be aware of potential rebound flare if high-potency corticosteroids are abruptly discontinued 1, 3
• Monitor for signs of skin atrophy or systemic absorption 2, 3
• Reassure parents about the safety of appropriate topical corticosteroid use, as fear of steroids often leads to undertreatment 1
• Do not use topical corticosteroids on areas without active eczema except for proactive weekend therapy on previously affected sites 4

When to Refer

• Failure to respond to first-line management after 6 weeks 5, 6
• Severe eczema requiring higher-potency steroids 5
• Recurrent infections 1
• Significant impact on quality of life despite treatment 5