What topical corticosteroid potencies, formulations, and treatment durations are appropriate for children of various ages (infants <2 years, children >2 years, adolescents >12 years) for conditions such as eczema, psoriasis, allergic contact dermatitis, and diaper dermatitis?

Topical Corticosteroid Use in Pediatric Dermatologic Conditions

For children with eczema, psoriasis, allergic contact dermatitis, and diaper dermatitis, topical corticosteroid selection must be stratified by age, anatomic site, and disease severity, with infants under 2 years requiring only low-potency agents (hydrocortisone 1-2.5%), children over 2 years tolerating mild-to-moderate potency steroids, and adolescents over 12 years safely using potent steroids for short courses on the trunk and extremities.

Age-Specific Potency Guidelines

Infants Under 2 Years

• Use only Class V/VI/VII low-potency corticosteroids (hydrocortisone 1% or 2.5% cream) due to their disproportionately high body surface area-to-volume ratio, which dramatically increases systemic absorption and risk of HPA axis suppression 1, 2.

• Infants aged 0-6 years, particularly those under 2 months, have thin, highly absorptive skin that makes them uniquely vulnerable to adverse effects even from medium-potency agents 1.

• FDA labeling for hydrocortisone specifies: For children under 2 years of age, ask a doctor before use; for children 2 years and older, apply to affected area not more than 3 to 4 times daily 3.

• Prescribe limited quantities with explicit written instructions on amount and application sites to prevent caregiver overuse 1.

• Avoid use on face, neck, and skin folds where absorption is highest; if facial treatment is necessary, consider topical calcineurin inhibitors (tacrolimus 0.03% ointment) as a safer alternative 1, 2.

Children Over 2 Years

• For mild eczema: Use low-potency corticosteroids (hydrocortisone 1%) 2.

• For moderate eczema: Use low-to-medium potency corticosteroids 2.

• For severe eczema: Use medium-to-high potency corticosteroids for short periods (3-7 days only) 2.

• Moderate-potency topical corticosteroids result in treatment success (cleared or marked improvement) in 52% versus 34% with mild-potency agents (OR 2.07,95% CI 1.41 to 3.04) 4.

• Potent topical corticosteroids achieve treatment success in 70% versus 39% with mild-potency agents (OR 3.71,95% CI 2.04 to 6.72) 4.

Adolescents Over 12 Years

• For psoriasis: Calcipotriol/betamethasone dipropionate combination applied once daily for up to 4 weeks is safe and effective (Recommendation strength B, evidence level I-II) 1.

• For scalp psoriasis: Calcipotriol/betamethasone dipropionate suspension once daily for up to 8 weeks achieves disease clearance in 58% of patients aged 12-17 years 1.

• Ultra-high-potency topical corticosteroids as monotherapy are effective for short-term treatment of localized psoriasis in pediatric patients (Recommendation strength C, evidence level II) 5.

Anatomic Site-Specific Recommendations

Face and Genital Areas

• Use only Class V/VI low-potency corticosteroids (hydrocortisone 2.5%) on facial skin to avoid atrophy 1, 2.

• Tacrolimus 0.1% ointment is recommended as off-label monotherapy for pediatric psoriasis of the face and genital region (Recommendation strength C, evidence level II-III) 5, 1.

• Tacrolimus achieves clearance or excellent improvement within 30 days in 88% of pediatric patients with facial or inverse psoriasis 1.

• Complete clearance of facial psoriasis was achieved within 72 hours in case series using tacrolimus 0.1% 1.

Trunk and Extremities

• Mild-to-moderate potency corticosteroids are appropriate based on disease severity 2.

• For acute flares, potent corticosteroids may be used for short courses (3-7 days) 2.

Diaper Area

• Use only low-potency agents (hydrocortisone 1-2.5%) due to natural occlusion from diapers, which increases absorption 1, 6.

• Consider barrier creams and frequent diaper changes as adjunctive measures 7.

Application Frequency and Duration

Frequency

• Once-daily application of potent topical corticosteroids is as effective as twice-daily application for treating eczema flare-ups (OR 0.97,95% CI 0.68 to 1.38) 4.

• Apply not more than 3 to 4 times daily per FDA labeling 3.

• Treatment should not be applied more than twice daily in most cases 2.

Duration for Acute Flares

• Short courses of 3-7 days are typically sufficient for acute flares 2.

• Super-high-potency corticosteroids should be used for up to 3 weeks maximum 6.

• High- or medium-potency corticosteroids may be used for up to 12 weeks 6.

• There is no specified time limit for low-potency topical corticosteroid use 6.

Maintenance and Proactive Therapy

Weekend (Proactive) Therapy

• Twice-weekly application of topical corticosteroids to previously affected areas prevents relapse, reducing flare-ups from 58% to 25% (RR 0.43,95% CI 0.32 to 0.57) 4.

• A common approach involves applying topical corticosteroids on weekends and calcitriol on weekdays after the initial 2 weeks of combination therapy 5, 1.

Rotational Therapy

• Consider rotational therapy with topical vitamin D analogs, topical calcineurin inhibitors, emollients, and topical corticosteroids as a steroid-sparing regimen to reduce adverse effects from excessive reliance on topical steroids 1.

• This approach is particularly useful in children requiring long-term management 1.

Condition-Specific Algorithms

Eczema/Atopic Dermatitis

1. Infants <2 years: Hydrocortisone 1-2.5% cream once or twice daily for 3-7 days 1, 2, 3.
2. Children 2-12 years with mild disease: Hydrocortisone 1% once or twice daily 2.
3. Children 2-12 years with moderate disease: Low-to-medium potency corticosteroids once or twice daily for up to 2 weeks 2.
4. Children 2-12 years with severe disease: Medium-to-high potency corticosteroids once daily for 3-7 days, then taper 2.
5. Maintenance: Twice-weekly proactive therapy to previously affected areas 4.
6. Adjunctive: Regular emollients have steroid-sparing effects 2.

Psoriasis

1. Children <12 years: Use low-to-moderate potency corticosteroids; avoid ultra-high-potency agents 5.
2. Adolescents ≥12 years with localized plaque psoriasis: Calcipotriol/betamethasone dipropionate once daily for up to 4 weeks 1.
3. Scalp psoriasis in adolescents ≥12 years: Calcipotriol/betamethasone dipropionate suspension once daily for up to 8 weeks 1.
4. Face and genitals (all ages): Tacrolimus 0.1% ointment as off-label monotherapy 5, 1.
5. Maintenance: Weekend corticosteroids alternating with weekday calcitriol after initial 2 weeks 5, 1.

Allergic Contact Dermatitis

1. All ages: Mild-to-moderate potency topical corticosteroids as first-line therapy 2.
2. Infants <2 years: Hydrocortisone 1-2.5% cream for 3-7 days 2.
3. Children >2 years: Low-to-moderate potency corticosteroids based on severity 2.
4. Face and genitals: Tacrolimus 0.03% ointment or hydrocortisone 2.5% 1, 2.

Diaper Dermatitis

1. Use only hydrocortisone 1-2.5% cream due to natural occlusion 1, 6.
2. Apply thin film once or twice daily for 3-7 days maximum 2, 3.
3. Emphasize barrier creams and frequent diaper changes 7.

Critical Safety Considerations

HPA Axis Suppression Risk Factors

• Highest risk: Infants 0-6 years, large body surface area application, occlusion, prolonged use, higher potency agents 1, 2, 6.

• HPA axis suppression can occur even with medium-potency steroids when used on large body surface areas or under occlusion 1.

• Assess growth parameters in infants requiring long-term topical corticosteroid therapy 1.

Local Adverse Events

• Abnormal skin thinning occurred in only 1% of participants across 22 trials (26 cases from 2266 participants), with most cases from higher-potency agents (16 with very potent, 6 with potent, 2 with moderate, 2 with mild) 4.

• Risk of adverse effects increases with higher potency, occlusion, prolonged use, and application to thinner skin areas 2, 6.

Rebound Flares

• Abrupt discontinuation of even low-potency steroids can cause rebound flares, though this is more concerning with higher-potency agents 1.

• Taper gradually after prolonged use to prevent rebound 1.

Common Pitfalls to Avoid

• Do not use high-potency or ultra-high-potency steroids in infants and young children due to dramatically increased systemic absorption 1, 2.

• Do not apply potent steroids to face, neck, or skin folds without considering topical calcineurin inhibitors as safer alternatives 1, 2.

• Do not prescribe large quantities without explicit instructions on amount and application sites, as caregiver overuse is common 1.

• Do not continue potent steroids beyond 3 weeks or medium-potency steroids beyond 12 weeks without reassessment 6.

• Do not abruptly discontinue after prolonged use; taper gradually to prevent rebound flares 1.