What is the recommended treatment for eczema in a child?

Treatment of Eczema in Children

The cornerstone of eczema management in children is liberal application of emollients at least twice daily combined with low-to-medium potency topical corticosteroids for active lesions, with treatment intensity escalated based on disease severity. 1, 2, 3

Basic Therapy for All Severity Levels

Emollient Application

• Apply emollients liberally at least twice daily and as needed throughout the day to maintain skin barrier function. 2, 3, 4
• Apply immediately after bathing when skin is most hydrated to lock in moisture. 2, 3, 4
• Use ointments or creams for very dry skin, particularly in winter months. 2
• Emollients containing urea and glycerol demonstrate superior barrier-strengthening properties compared to simple paraffin-based products. 5

Bathing Technique

• Use lukewarm water and limit bath time to 5-10 minutes to prevent excessive drying. 2
• Replace regular soaps with gentle, dispersible cream cleansers as soap substitutes since soaps remove natural lipids from the skin surface. 1, 2
• Pat skin dry and apply emollients immediately afterward. 2, 3

Trigger Avoidance

• Avoid extremes of temperature and maintain comfortable room temperatures. 1
• Use cotton clothing next to skin and avoid wool or synthetic fabrics that irritate. 1, 2, 3, 4
• Keep fingernails short to minimize scratching damage. 1, 2, 3, 4
• Avoid harsh detergents and fabric softeners when washing clothes. 2

Topical Corticosteroid Selection by Severity

Mild Eczema

• Use low-potency corticosteroids (hydrocortisone 1%) applied once or twice daily to affected areas until lesions significantly improve. 1, 2, 3, 4
• Apply topical corticosteroids once daily rather than twice daily—evidence shows equivalent efficacy with reduced exposure. 6

Moderate Eczema

• Use low-to-medium potency corticosteroids applied once daily. 1, 4
• Consider proactive therapy with twice-weekly application to previously affected areas to prevent relapses. 1, 4

Severe Eczema

• Use medium-to-high potency corticosteroids for short periods (3-7 days maximum). 4
• For very severe disease, add systemic immunomodulators (cyclosporine, methotrexate, azathioprine), biologics (dupilumab for children ≥6 years), or phototherapy (not recommended for children <12 years). 1

Critical Age-Specific Safety Considerations

• For infants, use ONLY hydrocortisone 1% (low-potency)—never use high-potency or ultra-high-potency corticosteroids due to dramatically increased risk of hypothalamic-pituitary-adrenal axis suppression from their high body surface area-to-volume ratio. 2, 3, 4
• For sensitive areas (face, neck, skin folds, genitals) in all ages, use only low-potency corticosteroids to avoid skin atrophy. 4
• Stop corticosteroids for short periods when possible to minimize side effects. 1, 4
• Provide only limited quantities with specific instructions on safe application sites. 2, 3
• Monitor for skin atrophy, striae, or signs of systemic absorption. 2, 3, 4

Second-Line Topical Agents (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, 3, 7
• Tacrolimus 0.03% ointment is approved for children aged 2 years and above (0.1% for ages 16+) and is valuable for face and genital regions. 1, 3, 4
• These agents are especially useful for sensitive areas where corticosteroid side effects are concerning. 4, 6

Other Topical Options

• Topical PDE-4 inhibitor (crisaborole) is approved for children ≥3 months for mild-to-moderate eczema. 1
• Ichthammol (1% in zinc ointment) is less irritant than coal tars and useful for lichenified areas. 4

Managing Complications

Secondary Bacterial Infection

• Watch for crusting, weeping, or worsening despite treatment—these indicate possible Staphylococcus aureus infection. 1, 2, 3
• Flucloxacillin is the first-choice antibiotic for S. aureus infections; erythromycin for penicillin-allergic patients. 2, 3, 4
• Avoid long-term topical antibiotics due to resistance and sensitization risk. 2, 3
• Evidence does not support routine use of oral or topical antistaphylococcal treatments for infected eczema. 6

Eczema Herpeticum (Herpes Simplex Infection)

• Grouped, punched-out erosions or vesiculation suggest herpes simplex infection. 1, 2
• Treat promptly with oral acyclovir; use intravenous acyclovir for ill, febrile patients. 2, 4
• Send smear for electron microscopy if herpes simplex infection is suspected. 1

Adjunctive Measures

Pruritus Management

• Sedating antihistamines may help short-term for sleep disturbance caused by itching, primarily at night. 2, 3, 4
• Non-sedating antihistamines have little value in atopic eczema and should not be routinely used. 2, 3, 4, 6

Treatments to Avoid (Lack Evidence)

• Emollient bath additives have not been shown to benefit eczema patients. 6
• Probiotics for treating eczema lack convincing evidence of benefit. 1, 6
• Silk clothing and ion-exchange water softeners have not demonstrated benefit. 6

Systemic Therapy for Severe Disease

Oral Corticosteroids

• Routine use of systemic corticosteroids is generally discouraged and 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 common rebound flares upon discontinuation. 1

Immunomodulators and Biologics

• For very severe disease refractory to topical therapy, consider cyclosporine, methotrexate, or azathioprine (off-label use). 1
• Dupilumab (biologic) is approved for children aged 6 years and above in Taiwan. 1

Parent and Patient Education Essentials

Application Technique

• Demonstrate proper application technique for emollients and medications—education is essential for treatment success. 1, 2, 3
• Provide written information to reinforce verbal instructions. 1, 2, 3
• Allow adequate time for explanation and discussion of treatment expectations. 1

Monitoring and Follow-Up

• Explain that deterioration in previously stable eczema may indicate infection or contact dermatitis. 1, 2
• Bacteriological swabs are not routinely indicated but may be necessary if patients do not respond to treatment. 1
• Record extent and severity of eczema at each visit. 1

Common Pitfalls to Avoid

• Undertreatment due to corticosteroid phobia—educate families that topical corticosteroids are safe when used appropriately with proper potency selection and monitoring. 1
• Using high-potency corticosteroids in infants or on sensitive areas—this dramatically increases risk of systemic absorption and adverse effects. 2, 3, 4
• Applying topical corticosteroids twice daily when once daily is equally effective. 6
• Prescribing non-sedating antihistamines for eczema when evidence shows no benefit. 6
• Abrupt discontinuation of corticosteroids leading to rebound flares. 2, 3