What is the appropriate management for eczema in an infant, including skin care, topical corticosteroids, antihistamines, infection treatment, and criteria for referral?

Management of Infant Eczema

For infant eczema, implement a structured regimen of liberal emollient therapy (at least twice daily), gentle bathing with soap substitutes, and low-potency topical corticosteroids (hydrocortisone 1%) for acute flares, while maintaining vigilance for secondary bacterial or viral infection that requires prompt antimicrobial treatment. 1, 2

Diagnosis and Initial Assessment

Diagnose atopic eczema clinically when an infant presents with an itchy skin condition (evidenced by scratching or rubbing behavior) plus three or more of the following features: 3, 4

• Facial involvement (cheeks or forehead) typical in children under 4 years 4
• Family history of atopic disease in first-degree relatives 3, 4
• Generalized dry skin in the past year 3, 4
• Personal history of asthma or hay fever 3
• Onset in the first two years of life 3

Critical red flags requiring immediate attention: 2, 4

• Crusting or weeping lesions suggest Staphylococcus aureus superinfection 3, 2
• Grouped "punched-out" erosions or vesiculation indicate eczema herpeticum (herpes simplex infection) 3, 2

First-Line Skin Care Management

Emollient Therapy (Foundation of Treatment)

Apply emollients liberally at least twice daily to the entire body, not just affected areas. 1, 2

• Use immediately after bathing to lock in moisture when skin is most hydrated 1
• Apply as needed throughout the day beyond the twice-daily minimum 1, 2
• Choose bland, thick preparations (creams or ointments) with minimal fragrances or preservatives 3
• Demonstrate proper application technique to parents and provide written instructions 1, 4

Bathing Recommendations

Bathe with lukewarm water 2-3 times per week for 5-10 minutes. 1

• Replace all soaps with gentle dispersible cream cleansers as soap substitutes 3, 1
• Soaps and detergents strip natural lipids from already-dry atopic skin 3
• Apply emollients immediately after patting skin dry 1

Topical Corticosteroids for Inflammatory Flares

Use hydrocortisone 1% as the appropriate low-potency topical corticosteroid for infants. 2

• Apply twice daily to inflamed areas during acute flares 3, 1
• Use the least potent preparation required to control symptoms 3, 1
• Stop for short periods when possible to avoid continuous use 3
• Explain to parents that appropriate topical corticosteroid use is safe; fear of steroids leads to undertreatment 1, 4
• Avoid very potent or potent preparations in infants due to high body surface area-to-volume ratio 1

Managing Secondary Infections

Bacterial Infection (Staphylococcus aureus)

When crusting or weeping is present, obtain bacterial swabs and initiate flucloxacillin for suspected S. aureus infection. 3, 2

• Flucloxacillin is the first-line antibiotic for Staphylococcus aureus, the most common pathogen 3, 2
• Use erythromycin if flucloxacillin resistance or penicillin allergy exists 3
• Phenoxymethylpenicillin is indicated if β-hemolytic streptococci are isolated 3

Eczema Herpeticum (Herpes Simplex Infection)

Initiate oral acyclovir immediately upon clinical suspicion of eczema herpeticum; this is a medical emergency. 3, 2, 4

• Grouped, punched-out erosions or vesiculopustular eruptions are pathognomonic 2, 4
• Start acyclovir early in the disease course 3
• Use intravenous acyclovir in ill, febrile infants 3
• Send smear for electron microscopy or viral culture 4
• Consider hospital admission if the infant appears ill or has widespread disease 2

Antihistamines

Use sedating antihistamines only short-term at nighttime for severe pruritus disrupting sleep. 3, 1

• The therapeutic value resides principally in sedative properties 3
• Large doses may be required in children 3
• Avoid daytime use 3
• Non-sedating antihistamines have little or no value in atopic eczema 3, 1
• Tachyphylaxis may progressively reduce effectiveness 3

Trigger Avoidance and Adjunctive Measures

Implement practical measures to minimize irritation and scratching: 3, 1, 2

• Keep fingernails short to minimize damage from scratching 3, 2
• Use cotton clothing next to skin; avoid wool or synthetic fabrics 3, 2
• Maintain comfortable room temperatures, avoiding excessive heat or cold 1, 2
• Avoid harsh detergents and fabric softeners when washing clothes 2
• Extremes of temperature should be avoided 3

Dietary Considerations

Dietary restriction should only be attempted in selected infants under professional supervision with dietitian involvement. 3, 1, 4

• Dietary manipulation is worth trying only when patient history strongly suggests specific food allergy or when widespread active eczema fails to respond to first-line treatment 3
• Dietary restriction rarely benefits eczema and may cause nutritional deficiencies 4
• Ensure nutritional adequacy before implementing any dietary changes 1

Parent Education Essentials

Allocate adequate time for demonstration and explanation; this is one of the most important aspects of management. 3, 4

• Demonstrate how to apply emollients and medications correctly 3, 1
• Provide written information to reinforce verbal instructions 3, 1, 4
• Explain that deterioration in previously stable eczema may indicate secondary infection or contact dermatitis requiring prompt evaluation 3, 1, 4
• Address corticosteroid fears explicitly, as undertreatment from steroid phobia is common 3, 1
• Educate about signs of infection (weeping, crusting, punched-out lesions) that require immediate medical attention 4

Criteria for Specialist Referral

Refer to dermatology or pediatric dermatology when: 3, 1, 4

• Eczema fails to respond to first-line management within 1-2 weeks 4
• Suspected eczema herpeticum (immediate referral) 4
• Extensive crusting or severe bacterial superinfection 4
• Diagnostic uncertainty exists 3
• Maximum waiting time for first specialist appointment should be six weeks 3

Common Pitfalls to Avoid

• Do not dismiss facial rashes as "baby acne" without evaluating for atopic features 4
• Do not overlook secondary bacterial or viral infection; these complications are common and necessitate targeted antimicrobial therapy 4
• Do not undertake dietary restriction without professional supervision 4
• Do not use high-potency or ultra-high-potency topical corticosteroids in infants 1
• Do not prescribe non-sedating antihistamines; they provide no benefit in atopic eczema 3, 1