A topical corticosteroid cream or ointment

The judicious use of an appropriate topical steroid is a safe and essential part of treatment. Creams are white and not very oily or greasy once applied. Ointments are like Vaseline and tend to feel somewhat oily or greasy for a while after they are applied. Ointments are reserved for more resistant areas where the skin is thick and dry. Topical corticosteroids should be applied once to twice daily specifically to the areas of inflammation, that is the areas that are red, pink, and itchy. One of the applications should be applied immediately after the evening bath, while the child's skin is still wet. The steroid should always be applied to the skin first and the emollient moisturizer applied after to all of the skin. Never apply the moisturizer just before the steroid. Topical corticosteroids are classified by their level of potency. The use of a relatively low potency topical steroid, such as 1% hydrocortisone is usually sufficient for most children. Occasionally, a medium potency steroid such as triamcinolone may be required. Nothing more potent than 1% hydrocortisone cream should be applied to sensitive areas such as the face or genitals, since sustained use of higher potency topical corticosteroids can cause thinning of the skin with permanent cosmetic changes. Topical corticosteroids should be stopped in areas that become clear. In general, it is best to avoid sustained use of topical corticosteroids for periods longer than 2 weeks at a time, although resumption is likely to be needed when inflamed areas return.

How to measure the amount of cream or ointment to apply:

  1. Open the tube of medication.
  2. Extend your index finger facing up.
  3. Squeeze out a line of medication from the tip of your finger to the first skin crease.
  4. Apply the medication to the affected area.

Amount of cream or ointment to use on affected area (in fingertip units):

  • Face and neck = 2 1/2
  • One arm = 3
  • One hand = 1
  • Trunk--front and back = 14
  • Groin = 1
  • One leg = 6
  • One foot = 2

Protopic (tacrolimus) and elidel (pimecrolimus)

These are the newest medication for atopic eczema. They are in a new class of drugs called “topical immunomodulators” or more commonly “topical calcineurin inhibitors” (abbreviated as TCIs). They currently are indicated primarily for atopic eczema that does not respond to conventional therapy with skin care and low potency topical corticosteroids. They are not a replacement for skin care but may provide an alternative to topical corticosteroids when those are not effective or require excessive use. A major advantage of these agents is the absence of the potential for thinning of the skin and cosmetic changes associated with the topical corticosteroids. Studies of continuous use in children for periods longer than a year have been associated with no adverse effects. While not necessarily having greater effectiveness that the more potent topical corticosteroids for clearing eczema, their ability to be used continuously with safety makes them useful as maintenance therapy for eczema that tends to flare shortly after a topical corticosteroid is stopped An appropriate topical corticosteroid can be applied for limited periods in addition to the regular application of the TCI for breakthrough eczematous flares. Although the FDA has placed a “black box” warning on the labeling of the TCIs, major allergy and dermatologic societies in the U.S. and Europe have taken exception to the implication of those warnings and emphasize the effectiveness and safety of the TCIs for use when intermittent use of appropriate topical corticosteroids are not adequate for control or require more frequent use or higher potency products than are safe.

Antihistamines

Although classical antihistamines such as diphenhydramine (Benadryl) and hydroxyzine (Atarax or Vistaril) have frequently been prescribed for atopic eczema, studies hav atopic eczema. While antihistamines relieve itching from hives, which are caused by histamine release, the underlying cause of the itching from atopic eczema is quite different from that of hives and involves mechanisms other than histamine. Since the classical antihistamines can cause some drowsiness, use of these at bedtime for short period may be useful to help the child sleep when they are itchy, but the sedative effects of these antihistamines do not persist with continued usage. There is no indication for the newer generation of antihistamines such as Claritin, Allegra, or Zyrtec since they provide little or no sedation. An exception to the evidence that antihistamines are of no value for atopic eczema would be for the occasional patient where continuing allergenic exposure is associated with flares of the eczema.

Antibiotics

The skin of children with atopic eczema is particularly prone to a common type of skin infection called impetigo. The bacteria that causes this is Staphylococcus aureus. Whenever crusting or oozing is observed, infection should be suspected and consideration needs to be given for an antibiotic such as cephalexin (Keflex) or dicloxacillin which are effective for treating Staphylococcus aureus. Other much less common types of infection that require treatment are Herpes simplex (the virus that causes cold sores). Consult your physician for any change in the character of the eczematous areas or any generalized spreading or increased severity.

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