What is the recommended treatment for eczema in children, specifically regarding topical corticosteroids and moisturizers?

Eczema Treatment for Children

For children with eczema, use liberal emollients at least twice daily combined with low-potency topical corticosteroids (hydrocortisone 1%) for flare-ups as the foundation of treatment. 1

First-Line Treatment Approach

Emollients (Moisturizers)

• Apply emollients liberally and frequently—at least twice daily and as needed throughout the day to maintain the skin barrier 1
• Ointments and creams work best for very dry skin or winter use 1
• Apply immediately after bathing to lock in moisture when skin is most hydrated 1
• Use a dispersible cream as a soap substitute instead of regular soap, which strips natural skin oils 2
• Regular emollient use has both short-term and long-term steroid-sparing effects 3

Topical Corticosteroids for Flares

Age-Appropriate Potency Selection:

• Infants and babies under 2 years: Use only low-potency corticosteroids (hydrocortisone 1%) 1, 4, 5
• Children 2 years and older with mild eczema: Low-potency corticosteroids (hydrocortisone 1%) 3
• Children with moderate eczema: Low to medium-potency corticosteroids 3
• Children with severe eczema: Medium to high-potency corticosteroids for short periods only (3-7 days) 3

Critical Safety Point: Never use high-potency or ultra-high-potency corticosteroids in infants—their high body surface area-to-volume ratio dramatically increases risk of hypothalamic-pituitary-adrenal axis suppression and systemic absorption 1, 4

Application Guidelines

• Apply once or twice daily to affected areas until lesions significantly improve 1, 4
• Once daily application is as effective as twice daily for potent corticosteroids 6
• Do not apply more than 3-4 times daily per FDA labeling 5
• Use the least potent preparation required to control the eczema 2, 4
• For face, neck, and skin folds, use only low-potency corticosteroids to avoid skin atrophy 3

Second-Line Steroid-Sparing Options

Topical Calcineurin Inhibitors

• Pimecrolimus 1% cream: FDA-approved for babies as young as 3 months, particularly useful for facial eczema 1, 4
• Tacrolimus 0.03% ointment: Approved for children aged 2 years and above, especially valuable for face and genital regions 1, 4
• These agents are excellent steroid-sparing alternatives for sensitive areas where corticosteroid side effects are most concerning 4

Proactive (Weekend) Therapy to Prevent Flares

For children with recurrent flares, apply topical corticosteroids twice weekly to previously affected areas even when clear to prevent relapses. 3, 6

• Weekend (proactive) therapy reduces relapse likelihood from 58% to 25% compared to reactive use only 6
• This approach is particularly effective for moderate to severe eczema 3

Managing Complications

Secondary Bacterial Infection

• Watch for crusting, weeping, or worsening despite treatment—these indicate possible Staphylococcus aureus infection 1, 4
• First-line antibiotic: Flucloxacillin for S. aureus 2, 1, 4
• Alternative: Erythromycin for penicillin-allergic patients 2, 3
• Avoid long-term topical antibiotics due to resistance and sensitization risk 1

Eczema Herpeticum (Herpes Simplex Infection)

• Look for grouped, punched-out erosions or vesiculation 2
• Treat promptly with oral acyclovir 1, 4

Adjunctive Measures

Itch Management

• Sedating antihistamines: Useful short-term for sleep disturbance caused by nighttime itching 2, 1, 3
• Non-sedating antihistamines: Have little to no value in atopic eczema 2, 1
• The therapeutic value of antihistamines resides primarily in their sedative properties 2

Environmental Modifications

• Use cotton clothing next to skin and avoid wool or synthetic fabrics 1, 4
• Keep fingernails short to minimize scratching damage 2, 1
• Avoid extremes of temperature 2
• Avoid irritants such as soaps and detergents 4

Critical Safety Monitoring

What to Watch For

• Monitor for skin atrophy, striae, or signs of systemic absorption 1, 3
• Provide caregivers with clear instructions on amount to apply, safe application sites, and treatment duration 1, 3
• Risk of adverse effects increases with higher potency, occlusion, and prolonged use 4, 3
• Avoid abrupt discontinuation of corticosteroids to prevent rebound flares 1, 4

Reassuring Long-Term Data

• Intermittent topical corticosteroid use for up to 5 years probably results in little to no difference in growth abnormalities or skin thinning when used appropriately 7
• In trials assessing flare treatment strategies, abnormal skin thinning occurred in only 1% of participants (26 cases from 2266 participants), mostly with higher-potency agents 6

Common Pitfalls to Avoid

• Undertreatment due to steroid phobia: Explain benefits and risks clearly to parents—topical corticosteroids are safe when used appropriately 2
• Using potent steroids in infants: This age group is particularly at risk of systemic side effects 8
• Neglecting emollients: These are the foundation of treatment, not just an add-on 1, 4
• Stopping treatment too early: Continue until lesions significantly improve, not just at first sign of improvement 1