What is the appropriate management for atopic dermatitis (eczema) in a 24‑month‑old child?

Management of Eczema in a 24-Month-Old Child

For a 24-month-old with atopic dermatitis, begin with liberal twice-daily emollients as the foundation of care, use low-to-medium potency topical corticosteroids for inflammatory flares, and avoid irritants through proper bathing and clothing choices. 1, 2

Stepwise Treatment Algorithm

Basic Therapy (All Patients)

• Apply emollients liberally at least twice daily to the entire body, not just affected areas, and immediately after bathing to lock in moisture when skin is most hydrated 2, 3
• Use lukewarm water for bathing, limit bath time to 5-10 minutes, and replace soaps with gentle dispersible cream cleansers 2
• Keep fingernails short to minimize scratching damage 2, 4
• Dress the child in cotton clothing next to skin; avoid wool or synthetic fabrics 2
• Avoid harsh detergents, fabric softeners, and maintain comfortable room temperatures 2

Mild Eczema

• Use reactive therapy with low-to-medium potency topical corticosteroids applied to inflamed areas during flares 1
• Alternative option: pimecrolimus cream 1% (approved for ages 3 months and above) as second-line therapy if topical corticosteroids fail or are not advisable 1, 5
• Crisaborole (topical PDE-4 inhibitor) is another alternative for patients aged 3 months and above 1

Moderate Eczema

• Preferred approach: proactive and reactive therapy with low-to-medium potency topical corticosteroids 1
• Consider pimecrolimus or tacrolimus 0.03% (approved for ages 2 years and above in Taiwan) as topical calcineurin inhibitor alternatives, particularly for facial involvement 1, 2
• Wet wrap therapy can be considered as adjunct treatment 1

Severe/Very Severe Eczema

• Continue topical corticosteroids (low to high potency) and topical calcineurin inhibitors 1
• Add-on therapy may include short-term oral corticosteroids (<7 days only), though long-term use is not recommended due to adverse effects 1
• Note: Phototherapy is not recommended for children younger than 12 years 1
• Immunomodulators and biologics (dupilumab approved for ages 6+ in Taiwan) are reserved for refractory cases 1

Critical Red Flags Requiring Urgent Action

Bacterial Superinfection

• Watch for crusting, weeping, honey-colored discharge, or extensive bacterial involvement 2, 3, 4
• Obtain bacterial swabs for culture when infection is suspected 3
• Treat with flucloxacillin as first-line antibiotic for Staphylococcus aureus (the most common pathogen) 2, 4

Eczema Herpeticum (Medical Emergency)

• Look for multiple uniform "punched-out" erosions or vesiculopustular eruptions 2, 3, 4
• Initiate immediate systemic acyclovir plus empirical antibiotics to cover secondary bacterial infection 4
• Send smear for electron microscopy or viral culture 3

Adjunct Therapies

Antihistamines

• Sedating antihistamines may be used short-term at night for sleep disturbance caused by severe itching 2
• Non-sedating antihistamines have little to no value in managing atopic eczema 2, 4

Dietary Considerations

• Dietary restriction should only be attempted in selected cases under professional dietitian supervision, as it rarely benefits eczema and may cause nutritional deficiencies 2, 3
• Complementary therapies such as probiotics and vitamin D have not demonstrated convincing benefits 1

Common Pitfalls to Avoid

• Do not abruptly discontinue high-potency corticosteroids without transitioning to appropriate alternative treatment, as this causes rebound flare 2, 4
• Avoid prolonged continuous use of topical corticosteroids to prevent pituitary-adrenal suppression and growth interference 4
• Do not dismiss facial rashes as "baby acne" without evaluating for atopic features 3
• Do not overlook secondary bacterial or viral infections, which are common complications requiring targeted antimicrobial therapy 3

Parent Education Essentials

• Demonstrate proper application technique for emollients and medications, emphasizing generous use 2, 3
• Provide written instructions to reinforce verbal teaching 2, 4
• Explain that deterioration in previously stable eczema may indicate infection or contact dermatitis requiring prompt medical attention 2, 3
• Address parental fears about corticosteroid safety, reassuring that appropriate use is safe 3, 4
• Educate about signs of infection: weeping, crusting, or punched-out lesions 3

Follow-Up and Referral

• Reassess in 1-2 weeks if no improvement occurs with initial therapy 4
• Consider referral to a specialist if eczema fails to respond to first-line management, if eczema herpeticum is suspected, or if extensive crusting or severe bacterial superinfection is present 2, 3