What are the management options for atopic dermatitis (eczema) in an 18-month-old child?

From the Guidelines

For managing eczema in an 18-month-old child, a stepwise treatment approach should be considered, starting with gentle skincare, trigger avoidance, and topical treatments, with the option for off-label use of topical calcineurin inhibitors like pimecrolimus (Elidel) as per the Taiwan guidelines for pediatric atopic dermatitis 1. When managing eczema in an 18-month-old child, it's essential to focus on gentle skincare and trigger avoidance.

• Use a daily gentle, fragrance-free cleanser like Cetaphil or CeraVe,
• followed by liberal application of a thick moisturizer such as petroleum jelly, Eucerin, or Vanicream within 3 minutes of bathing to lock in moisture.
• Apply moisturizer at least 2-3 times daily. For flare-ups,
• use a low-potency topical steroid like 1% hydrocortisone cream twice daily for up to 7 days on affected areas,
• avoiding medium or high-potency steroids on a toddler's delicate skin. Keep the child's fingernails short to minimize damage from scratching. Dress them in soft, cotton clothing and avoid known triggers like harsh soaps, bubble baths, fragrances, and potential food allergens. Maintain a cool, humid environment in the home, as heat and dryness can worsen symptoms. If the eczema doesn't improve with these measures, or if there are signs of infection (increased redness, warmth, yellow crusting), consult a healthcare provider promptly. They may recommend a short course of an antihistamine like cetirizine (Zyrtec) at 2.5mg daily for nighttime itching or prescribe non-steroidal alternatives like pimecrolimus (Elidel) for sensitive areas, considering the recent guidelines that support its use in children as young as 3 months 1. Given the age of the child and the need for careful consideration of treatment options, the use of pimecrolimus (Elidel) as an off-label treatment for eczema in an 18-month-old child may be considered, based on the most recent guidelines from the Taiwan Academy of Pediatric Allergy, Asthma and Immunology 1.

From the FDA Drug Label

Two of the three trials support the use of ELIDEL Cream in patients 2 years and older with mild to moderate atopic dermatitis

• Eczema management for an 18-month-old patient is not directly supported by the provided drug label, as the supported age range is 2 years and older.
• The drug label does not provide sufficient information to make a clinical decision for a patient of this age. 2

From the Research

Eczema Management in 18-Month-Old Children

Overview of Treatment Options

Eczema, also known as atopic dermatitis, is a chronic inflammatory skin condition that affects children and adults, significantly impacting quality of life. For an 18-month-old child, management of eczema involves various treatment options, including topical corticosteroids, topical calcineurin inhibitors (TCIs) like tacrolimus and pimecrolimus, and other topical agents.

Topical Corticosteroids and Calcineurin Inhibitors

• Topical corticosteroids (TCS) are the first-line therapy for eczema but can have significant adverse effects with chronic use 3.
• Tacrolimus ointment, a TCI, is an alternative treatment that has shown efficacy in managing moderate to severe atopic dermatitis, especially when compared to low-potency TCS or pimecrolimus 1% 3, 4.
• Pimecrolimus is less effective than moderate and potent corticosteroids and 0.1% tacrolimus but may be considered for mild to moderate eczema, particularly for its role in preventing flares and improving quality of life 5, 6.

Safety and Efficacy Considerations

• The safety profile of tacrolimus includes a higher incidence of burning sensations compared to corticosteroids, but serious adverse events are rare 3, 4.
• Pimecrolimus is associated with more overall withdrawals and skin burning compared to some corticosteroids but is generally well-tolerated 5.
• The long-term safety of these treatments, especially regarding the risk of malignancies or skin atrophy, has been evaluated, with current evidence suggesting no significant increased risk 3, 4, 7.

Network Meta-Analysis Findings

• Network meta-analyses have ranked potent/very potent TCS, tacrolimus 0.1%, and certain Janus kinase inhibitors among the most effective treatments for improving patient-reported symptoms and clinician-reported signs of eczema 4, 7.
• Tacrolimus 0.1% and crisaborole 2% are more likely to cause local application-site reactions, while TCS are least likely to cause such reactions 4, 7.

Conclusion on Treatment Choice

Given the available evidence, the choice of treatment for an 18-month-old child with eczema should be based on the severity of the condition, the presence of any contraindications, and considerations regarding the safety and efficacy of the available options. Topical corticosteroids remain a first-line option, but tacrolimus and other TCIs offer viable alternatives, especially in cases where corticosteroids are not suitable or effective. Consultation with a healthcare professional is essential to determine the most appropriate treatment plan.