What is the recommended stepwise treatment for a child with atopic eczema?

Stepwise Treatment for Pediatric Atopic Eczema

Begin with liberal emollients (≥200-400 g/week) applied at least twice daily plus low-potency topical corticosteroids (hydrocortisone 1% for infants, low-to-medium potency for older children) for active lesions, escalating to topical calcineurin inhibitors if inadequate control within 1-2 weeks, then wet-wrap therapy, and finally systemic agents (dupilumab for children ≥6 months or immunomodulators) for severe refractory disease. 1, 2, 3

Step 1: Foundation Therapy (All Patients, All Severities)

Emollients and Skin Hydration

• Apply emollients liberally at least twice daily and as needed throughout the day—aim for 200-400 g per week. 2, 3, 4
• Apply immediately after bathing to lock in moisture when skin is most hydrated. 2, 3, 4
• Use ointments or creams for very dry skin, particularly in winter. 4
• Emollients provide both short- and long-term steroid-sparing effects in mild to moderate disease. 1

Bathing Technique

• Use lukewarm water and limit bath time to 5-10 minutes. 2, 4
• Replace regular soaps with gentle, dispersible cream cleansers as soap substitutes. 1, 2, 4

Trigger Avoidance

• Identify and avoid specific triggers including dry skin, excessive sweating, temperature/humidity changes, irritants, allergens, infections, and stress. 1
• Use cotton clothing next to skin and avoid wool or synthetic fabrics. 2, 4
• Keep fingernails short to minimize scratching damage. 2, 4
• Avoid harsh detergents and fabric softeners. 4

Step 2: First-Line Anti-Inflammatory Treatment

Topical Corticosteroids (TCS)

TCS are the first-line treatment for flare-ups and effectively reduce inflammatory immune response. 1

Age-Appropriate Potency Selection

• Infants and young children: Use only low-potency TCS (hydrocortisone 1%) due to increased risk of adrenal suppression from high body surface area-to-volume ratio. 1, 3, 4
• Older children: Low-to-medium potency TCS for trunk and extremities. 1
• Sensitive areas (face, neck, skin folds): Use low-potency TCS with extreme caution and limit duration to avoid skin atrophy. 1, 3

Application Guidelines

• Apply once or twice daily to affected areas for 3-7 days, then reassess. 3
• Do not continue daily application beyond 7 days without reassessment. 3
• After acute control, transition to proactive maintenance with twice-weekly application to previously affected areas to prevent relapses in moderate to very severe disease. 1, 3

Critical Safety Considerations

• Never use high-potency or ultra-high-potency TCS in infants—risk of hypothalamic-pituitary-adrenal axis suppression is dramatically elevated. 3, 4
• Avoid abrupt discontinuation; taper to proactive maintenance to prevent rebound flares. 3
• Provide only limited quantities with specific instructions on safe application sites. 2, 3

Step 3: Second-Line Topical Therapy (If Inadequate Response to TCS)

Topical Calcineurin Inhibitors (TCIs)

TCIs are steroid-sparing immunomodulators that avoid corticosteroid-related adverse effects such as skin atrophy and HPA-axis suppression. 1, 3

• Pimecrolimus 1% cream: FDA-approved for infants ≥3 months, particularly useful for facial eczema. 3, 4
• Tacrolimus 0.03% ointment: FDA-approved for children ≥2 years, valuable for face and genital regions. 1, 3, 4
• Use TCIs for patients aged 2 years and above who fail to respond to TCS. 1, 5
• Proactive twice-weekly TCI application to previously affected areas helps prevent relapses. 1

Topical PDE-4 Inhibitors

• Topical phosphodiesterase-4 inhibitors are approved for mild to moderate atopic dermatitis. 1

Step 4: Intensive Topical Therapy (Moderate to Very Severe Disease)

Wet-Wrap Therapy

Wet-wrap therapy with TCS is an effective and relatively safe short-term second-line treatment for moderate to very severe disease. 1

• Recommended duration: 3-7 days, with possible extension to maximum 14 days in severe cases. 1
• Consider wet-wrap therapy ahead of systemic immunosuppressive therapies for patients failing conventional topical therapy. 1
• Wet dressings promote trans-epidermal penetration of TCS and serve as barriers against persistent scratching. 1

Step 5: Systemic Therapy (Severe to Very Severe Refractory Disease)

Biologic Therapy

Dupilumab is the first approved biologic treatment for atopic dermatitis and is recommended for severe to very severe disease refractory to conventional topical treatment. 1

• FDA-approved for infants ≥6 months with moderate-to-severe disease uncontrolled by topical agents. 3
• Clinical trial data show 69.7% rate of EASI-75 improvement after 16 weeks in children 6-11 years. 3
• Common adverse events include conjunctivitis, facial erythema, injection-site reactions, and herpes simplex infection. 3

Systemic Immunomodulators

Immunomodulators including cyclosporin, azathioprine, and methotrexate may be used in children with very severe disease. 1

• Adjust to minimal effective dose once treatment response is attained and sustained. 1
• The combination of immunomodulators and phototherapy is not recommended. 1

Oral Corticosteroids

Long-term use of oral corticosteroids is not recommended due to unfavorable risk-benefit profile. 1

• Short-course oral corticosteroids (<7 days) may be used for severe acute flares, but recent evidence indicates increased risk of serious adverse events even with brief exposure; rebound flares are common after abrupt cessation. 3
• Systemic corticosteroids should not be considered for maintenance treatment until all other avenues have been explored. 1

Adjunctive Therapies

Antihistamines

Oral antihistamines are recommended as adjuvant therapy for reducing pruritus. 1

• Sedating antihistamines are useful short-term for sleep disturbance caused by itching, primarily at night. 1, 2, 4
• Non-sedating antihistamines have little or no value in atopic eczema. 1, 2, 4
• Large doses may be required in children. 1

Management of Secondary Infection

Use systemic antibiotics exclusively in children with clinical evidence of bacterial infection while on standard treatment. 1

• Flucloxacillin is the most appropriate antibiotic for treating Staphylococcus aureus, the commonest pathogen. 1, 2, 3, 4
• Long-term application of topical antibiotics is not recommended due to increased risk of resistance and sensitization. 1
• In moderate to severe disease with clinical signs of secondary bacterial infection, intranasal mupirocin and bleach baths may reduce disease severity. 1
• For eczema herpeticum (herpes simplex infection), initiate oral acyclovir promptly; in ill feverish patients, give acyclovir intravenously. 1, 2, 3, 4

Phototherapy

Phototherapy is not recommended for children younger than 12 years as the long-term safety profile remains unclear. 1

Common Pitfalls to Avoid

• Do not use potent or ultra-potent steroids as first-line therapy in infants. 3
• Do not delay treatment of secondary infection, as bacterial superinfection markedly worsens disease control. 3
• Do not continue daily topical corticosteroid application beyond 7 days without reassessment. 3
• Watch for crusting, weeping, or worsening despite treatment—these indicate possible secondary infection. 2, 3, 4
• Deterioration in previously stable eczema may indicate infection or contact dermatitis. 2, 4

Referral Criteria

Refer to a pediatric dermatologist when low-potency steroid therapy fails to achieve control within 1-2 weeks of appropriate use. 3

• Refer when second-line topical agents or dietary manipulation are being considered, or when diagnostic uncertainty exists. 3
• Most patients respond well to first-line management and do not require specialist referral. 1