What are the treatment options for a child with eczema?

Treatment of Eczema in Children

Topical corticosteroids combined with liberal emollient use form the foundation of eczema treatment in children, with hydrocortisone 1% (low-potency) as first-line for infants and mild-to-moderate potency corticosteroids for older children with more severe disease. 1, 2

First-Line Treatment Strategy

Emollients: The Essential Foundation

• Apply emollients liberally at least twice daily and as needed throughout the day to maintain skin barrier function 1, 2
• Apply immediately after bathing (within 3 minutes) when skin is most hydrated to lock in moisture 1
• Use ointments or creams for very dry skin, particularly in winter months 1
• Emollients have both short-term and long-term steroid-sparing effects 2

Topical Corticosteroids: Potency Selection by Age and Severity

For infants (under 2 years):

• Use only hydrocortisone 1% (low-potency) applied once or twice daily to affected areas 1, 2
• Never use high-potency or ultra-high-potency corticosteroids in infants due to dramatically increased risk of hypothalamic-pituitary-adrenal axis suppression from their high body surface area-to-volume ratio 1, 2

For children 2 years and older:

• Mild eczema: hydrocortisone 1% (low-potency) 2
• Moderate eczema: low-to-medium potency corticosteroids 2
• Severe eczema: medium-to-high potency corticosteroids for short periods (3-7 days) 2
• For sensitive areas (face, neck, skin folds, genitals): use only low-potency corticosteroids regardless of severity to avoid skin atrophy 2, 3

The evidence strongly supports that moderate-potency topical corticosteroids result in more participants achieving treatment success compared to mild-potency (52% versus 34%), and potent topical corticosteroids show even greater benefit (70% versus 39%) 4. However, there is insufficient evidence that very potent topical corticosteroids provide additional benefit over potent preparations 4.

Application Frequency and Technique

• Apply topical corticosteroids once or twice daily—once daily application of potent topical corticosteroids is equally effective as twice daily application 3, 4
• Use the least potent preparation required to control symptoms 5, 3
• Apply to affected areas only until lesions significantly improve, then stop for short periods when possible to minimize side effects 5, 1
• The order of application (emollient first versus corticosteroid first) does not matter—parents can apply in whichever order they prefer 6

Bathing and Skin Care Practices

• Use lukewarm water and limit bath time to 5-10 minutes to prevent excessive drying 1
• Replace regular soaps with gentle, dispersible cream cleansers as soap substitutes since soaps remove natural lipids 5, 1
• Apply emollients immediately after patting skin dry to trap moisture 5, 1
• Avoid extremes of temperature 5
• Use cotton clothing next to skin and avoid wool or synthetic fabrics 5, 1
• Keep fingernails short to minimize scratching damage 5, 1

Second-Line Topical Treatments (Steroid-Sparing Agents)

Topical calcineurin inhibitors are effective alternatives for sensitive areas and when corticosteroid side effects are a concern:

• Pimecrolimus 1% cream is FDA-approved for children as young as 3 months and is particularly useful for facial eczema 1, 7
• Tacrolimus 0.03% ointment is FDA-approved only for children aged 2 years and above 1, 7
• Tacrolimus 0.03% applied once or twice daily is more efficacious than hydrocortisone 1% in children with moderate-to-severe atopic dermatitis, with twice daily application showing greatest improvement especially in severe disease 8
• Both agents are effective for sensitive areas such as face and genital regions 2

Critical FDA safety warnings for pimecrolimus: Do not use continuously for long periods, use only on areas with eczema, and do not use in children under 2 years old due to unknown long-term safety effects on the developing immune system 7

Managing Secondary Infections

Bacterial Infection (Staphylococcus aureus)

Watch for these signs indicating bacterial infection:

• Crusting or weeping 5, 1
• Pustules 3
• Worsening despite appropriate treatment 5

Treatment approach:

• Flucloxacillin is the first-choice oral antibiotic for Staphylococcus aureus infections 1, 2, 3
• Erythromycin may be used for penicillin-allergic patients 2
• Continue topical corticosteroids during bacterial infection when appropriate systemic antibiotics are given concurrently—do not delay or withhold corticosteroids 3
• Avoid long-term topical antibiotics due to resistance and sensitization risk 1

Viral Infection (Eczema Herpeticum)

This is a medical emergency. Watch for these signs:

• Grouped, punched-out erosions 5, 1
• Discrete vesicles 5
• Sudden deterioration with fever 3

Treatment approach:

• Initiate oral acyclovir promptly and early in the disease course 1, 2, 3
• Use intravenous acyclovir for ill, febrile patients 1, 2, 3

Proactive (Maintenance) Therapy to Prevent Relapses

For children with recurrent flares, twice-weekly application of topical corticosteroids to previously affected areas prevents relapses:

• Apply topical corticosteroids twice weekly (weekend or "proactive therapy") to areas that typically flare 2, 3
• This approach results in a large decrease in likelihood of relapse from 58% to 25% 4
• Continue this regimen for 16-20 weeks or as directed 4

Managing Pruritus (Itching)

• Sedating antihistamines may help short-term for sleep disturbance caused by nighttime itching, primarily through their sedative properties 1, 2, 3
• Non-sedating antihistamines have little to no value in atopic eczema and should not be used 1, 2, 3

Parent and Caregiver Education

Education is one of the most important aspects of management:

• Demonstrate proper application technique for emollients and medications 1, 2
• Provide written information to reinforce verbal instructions 5, 1
• Explain different corticosteroid potencies and their benefits/risks, as patients' or parents' fears of steroids often lead to undertreatment 5, 3
• Explain that deterioration in previously stable eczema may indicate infection or contact dermatitis 5, 1
• Educate about the quantity to use—adequate amounts must be prescribed and used liberally 5

Safety Monitoring and Common Pitfalls

Monitor for corticosteroid adverse effects:

• Watch for skin atrophy, striae, or signs of systemic absorption 1, 2
• Provide only limited quantities with specific instructions on safe application sites 1
• Avoid abrupt discontinuation to prevent rebound flares 1
• Implement "steroid holidays" when possible 3

Common pitfalls to avoid:

• Do not use very potent corticosteroids in thin-skinned areas (face, neck, flexures, genitals) where risk of atrophy is higher 3
• Do not use high-potency or ultra-high-potency corticosteroids in infants and young children 1, 2
• Do not delay topical corticosteroids when infection is present if appropriate systemic antibiotics are given 3

Within trials testing eczema flare-up strategies, abnormal skin thinning occurred in only 1% of participants (26 cases from 2266 participants across 22 trials), with most cases from higher-potency preparations 4. In proactive therapy trials lasting 16-20 weeks, no cases of abnormal skin thinning were identified in 1050 participants 4.

When to Refer or Escalate Care

• Failure to respond to moderate-potency topical corticosteroids after 4 weeks 3
• Symptoms do not improve after 6 weeks of treatment 7
• Need for systemic therapy or phototherapy 3
• Suspected eczema herpeticum (medical emergency) 3