First-Line Topical Corticosteroid for Mild Eczema in a 6-Month-Old

For a 6-month-old with mild eczema refractory to emollients, use hydrocortisone 1% ointment applied twice daily to affected areas. 1

Steroid Potency Selection

Hydrocortisone 1% is the appropriate first-line topical corticosteroid for infants with mild eczema. 2
This represents a Class V/VI (mild potency) topical corticosteroid, which is specifically recommended for facial and body use in young children. 2
The Taiwan Academy of Pediatric Allergy, Asthma and Immunology guidelines emphasize starting with low to medium potency topical corticosteroids in children with mild to moderate atopic dermatitis. 2
Higher potency steroids (Class I-II) should be reserved for more severe disease or areas with thicker skin, not for initial treatment of mild eczema in infants. 2

Ointment is preferred over cream for infants with eczema. 2

Ointments provide superior occlusive properties, maximizing medication penetration and moisture retention in the skin. 2
Ointments are particularly suitable for very dry skin, which is characteristic of eczema. 2
Creams are water-based and less occlusive, making them less effective for the dry, compromised skin barrier seen in eczema. 2
The only exception would be if the infant has significant weeping or maceration, where a cream might be temporarily preferred, but this is uncommon in mild eczema. 2

Apply hydrocortisone 1% ointment twice daily to affected areas until lesions significantly improve. 2
Treatment duration should typically be 1-2 weeks for a flare, though evidence on optimal duration is limited. 3
Once control is achieved, consider transitioning to weekend (proactive) application to prevent relapses, though this strategy is better studied in older children. 3

Continue aggressive emollient therapy alongside topical corticosteroids. 2

Apply fragrance-free emollient ointment or cream at least twice daily, ideally immediately after bathing. 2
Emollients should be applied at different times from the topical corticosteroid or at least 15-30 minutes apart. 2
Recent evidence shows no significant difference between lotion, cream, gel, or ointment emollients for effectiveness, so parental preference can guide emollient selection. 4, 5

Avoid using hydrocortisone 1% on large body surface areas in infants due to increased risk of systemic absorption. 2
The risk of skin atrophy with mild-potency steroids like hydrocortisone 1% is very low when used appropriately for short durations. 3
In trials comparing different steroid potencies, abnormal skin thinning occurred in only 1% of participants, with most cases from higher-potency preparations. 3
Monitor for local adverse effects including skin thinning, though this is rare with hydrocortisone 1%. 3

If no improvement after 2-3 weeks of hydrocortisone 1% ointment twice daily plus emollients, consider referral to dermatology or pediatrics. 6
Moderate-potency topical corticosteroids (such as fluticasone or mometasone) may be needed for refractory cases, but this should be done under specialist guidance in a 6-month-old. 2
For facial or intertriginous involvement that doesn't respond to hydrocortisone, topical calcineurin inhibitors (tacrolimus 0.03%) may be considered as a steroid-sparing alternative, though this is off-label in infants. 2

Do not use potent or very potent topical corticosteroids as first-line therapy in infants with mild eczema. 2
Avoid products containing urea, salicylic acid, or other active ingredients in infants due to increased percutaneous absorption risk. 2
Do not apply topical corticosteroids and emollients simultaneously, as this may dilute the steroid and reduce efficacy. 2
Ensure parents understand that twice-daily application is as effective as more frequent application, preventing unnecessary overuse. 3