What is the most effective treatment approach for a pediatric patient with eczema?

Management of Pediatric Eczema

Start with liberal emollient application at least twice daily (200-400g per week) combined with low-to-medium potency topical corticosteroids applied once or twice daily to active lesions, escalating potency and adding systemic therapies only for severe refractory disease. 1, 2, 3

Basic Foundation Therapy (All Severity Levels)

Emollients - The Cornerstone

• Apply fragrance-free emollients liberally at least twice daily and as needed throughout the day to maintain skin barrier function 2, 3, 4
• Use 200-400g per week for adequate coverage 3
• Apply immediately after a 10-15 minute lukewarm bath when skin is most hydrated to lock in moisture 2, 3, 4
• Ointments and creams are preferred for very dry skin or winter use 2, 4
• Regular emollient use has both short-term and long-term steroid-sparing effects 3

Trigger Avoidance

• Replace regular soaps with gentle, dispersible cream cleansers as soap substitutes since soaps remove natural lipids 4, 1
• Use cotton clothing next to skin and avoid wool or synthetic fabrics 2, 3, 4
• Keep fingernails short to minimize scratching damage 2, 3, 4
• Avoid harsh detergents and fabric softeners when washing clothes 4
• Maintain comfortable room temperatures, avoiding excessive heat 4

Topical Corticosteroid Therapy - Stepwise by Severity

Mild Eczema

• Use reactive therapy with low-potency topical corticosteroids (hydrocortisone 1%) applied once or twice daily to affected areas until lesions significantly improve 1, 3
• Apply for 1-4 weeks during flares 1

Moderate Eczema

• Use proactive and reactive therapy with low-to-medium potency topical corticosteroids (fluticasone or mometasone) 1, 3
• Apply once or twice daily during flares for 1-4 weeks 1, 3
• Transition to twice-weekly maintenance on previously affected areas after clearance 1, 3
• Moderate-potency topical corticosteroids result in more participants achieving treatment success compared to mild-potency (52% versus 34%; OR 2.07) 5

Severe to Very Severe Eczema

• Use medium-to-high potency topical corticosteroids for short periods (3-7 days maximum) on the body 1, 3
• Potent topical corticosteroids result in a large increase in treatment success compared to mild-potency (70% versus 39%; OR 3.71) 5
• Add systemic therapies for refractory cases (see below) 1

Location-Specific Guidance

• Use only low-potency corticosteroids (hydrocortisone 1%) on the face, neck, and skin folds to avoid skin atrophy 1, 3
• Consider topical calcineurin inhibitors as alternatives for sensitive areas 1, 3

Application Frequency

• Once daily application of potent topical corticosteroids is as effective as twice daily application (OR 0.97) 5
• Treatment should not be applied more than twice daily 1

Steroid-Sparing Alternatives

Topical Calcineurin Inhibitors

• Pimecrolimus 1% cream is FDA-approved for children as young as 3 months and is particularly useful for facial eczema 2, 6
• In trials, 35% of patients treated with pimecrolimus were clear or almost clear compared to 18% with vehicle 6
• Tacrolimus 0.03% ointment is approved for children aged 2 years and above, especially valuable for face and genital regions 1, 2, 3

Proactive Maintenance Therapy

• Apply topical corticosteroids twice weekly (weekend therapy) to previously affected areas to prevent relapses 1, 3
• Weekend proactive therapy results in a large decrease in likelihood of relapse from 58% to 25% (RR 0.43) 5
• This approach reduces total steroid exposure while maintaining disease control 3

Managing Complications

Secondary Bacterial Infection

• Watch for crusting, weeping, or worsening despite treatment—these indicate secondary bacterial infection (usually Staphylococcus aureus) 2, 3, 4
• Flucloxacillin is the first-choice antibiotic for S. aureus infections 1, 2, 4
• Phenoxymethylpenicillin should be given if β-hemolytic streptococci are isolated 1
• Erythromycin may be used when there is resistance to flucloxacillin or in patients with penicillin allergy 1
• Avoid long-term topical antibiotics due to resistance and sensitization risk 2, 4

Viral Infections

• Grouped, punched-out erosions suggest herpes simplex infection (eczema herpeticum) 4
• Treat eczema herpeticum promptly with oral acyclovir given early in the course of disease 1, 2, 4
• In ill, feverish patients, acyclovir should be given intravenously 1

Adjunctive Therapies

Antihistamines

• Sedating antihistamines may help short-term for sleep disturbance caused by itching, primarily at night 1, 2, 3, 4
• Large doses may be required in children 1
• Daytime use should be avoided 1
• Non-sedating antihistamines have little or no value in atopic eczema 1, 2, 4
• The value of antihistamines may be progressively reduced due to tachyphylaxis 1

Systemic Therapies for Severe Refractory Disease

When to Consider Systemic Therapy

• Baseline severity of moderate-to-severe disease with significant impact on quality of life 1
• Lack of response to intensive topical therapy (medium-to-high potency topical corticosteroids for 1-4 weeks) 1
• Consider wet wrap therapy and soak-and-seal techniques before escalating 1
• Ensure adequate patient education has been provided, including trigger avoidance, adherence optimization, and addressing topical steroid phobia 1

Biologic Therapy

• Dupilumab is FDA-approved for patients aged 6 years and above with moderate-to-severe eczema inadequately controlled by conventional therapies 1
• Dupilumab achieved EASI-75 improvement in 41.5% of adolescents and 69.7% of children aged 6-11 years after 16 weeks 1
• Common adverse effects include conjunctivitis, facial redness, injection site reactions, and herpes simplex virus infection 1

Oral Small Molecule JAK Inhibitors

• Baricitinib (JAK1/2 inhibitor) is approved for patients aged 18 years and above, demonstrating EASI-75 improvement in 70% of patients 1
• Upadacitinib (JAK1 inhibitor) is approved for patients aged 12 years and above, demonstrating EASI-75 improvement in 77% of patients 1
• Common side effects include nausea, nasopharyngitis, and acne/folliculitis 1
• Laboratory monitoring of hemogram, liver enzymes, and lipid levels is recommended 1

Traditional Immunosuppressants

• Cyclosporine is used off-label for severe cases with an onset of action of 8-12 weeks 1
• Methotrexate is used off-label with doses of 1-4 mg/kg/day in pediatrics 1
• Azathioprine is used off-label with doses of 1-4 mg/kg/day in pediatrics, with slow onset of action of 8-12 weeks 1
• Side effects include bone marrow suppression, liver toxicity, GI upset, infection, and increased risk of malignancy 1

Systemic Corticosteroids

• Routine use is generally discouraged and should be reserved only for special circumstances 1
• Low dose and short-term use (<7 days) may be considered for severe acute exacerbations 1
• Long-term use is not recommended due to well-known adverse effects and risk of rebound flares upon discontinuation 1
• Recent evidence suggests short-term use is associated with a small but significantly increased risk of severe adverse events 1

Phototherapy

• Narrowband ultraviolet B (NB-UVB) is a second-line therapy for moderate-to-severe eczema refractory to topical agents 1
• Phototherapy is not recommended for children younger than 12 years 1
• There is a well-recognized delay in onset of efficacy, often more than 4 weeks 1

Critical Safety Considerations

Topical Corticosteroid Safety

• 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 2, 4
• The main risk is suppression of the pituitary-adrenal axis with possible interference of growth in children 1
• Monitor for skin atrophy, striae, or signs of systemic absorption 2, 4
• Provide only limited quantities with specific instructions on safe application sites 2, 4
• Avoid abrupt discontinuation of corticosteroids to prevent rebound flares 2, 4
• Do not continue daily corticosteroid application beyond 7 days without reassessment—transition to proactive twice-weekly maintenance instead 3
• In trials reporting abnormal skin thinning, frequency was low overall (1% across 22 trials) and increased with increasing potency 5

Parent Education Essentials

Application Technique

• Demonstrate proper application technique for emollients and medications 4
• Provide written information to reinforce verbal instructions 4
• Education regarding the application of topical preparations and the quantity to use is essential 1
• Allow adequate time for explanation and discussion 1

Expectations and Follow-Up

• Explain that deterioration in previously stable eczema may indicate infection or contact dermatitis 4
• Most children with eczema will respond well to first-line management and do not require referral to a specialist 1
• Failure to respond to treatment is an indication for referral to a hospital specialist 1

Common Pitfalls to Avoid

• Avoid using high-potency or ultra-high-potency steroids as first-line for moderate disease 3
• Consider poor treatment adherence or alternative diagnoses if treatment response is inadequate 3
• Do not use evening primrose oil or borage oil—two large trials showed no benefit 3
• Homeopathic remedies lack scientific evidence to support their use 3
• Dietary manipulation is only indicated when history strongly suggests specific food allergy or when first-line treatment fails 1, 3
• Chinese herbal medicines carry hepatotoxicity risk and require regular liver function monitoring 3