Situation:

Lilly is a 6-year-old girl who presents with a 2-week history of worsening redness, dryness, and
rash to the volar aspects of the wrist and dorsum of the hands. The area is moderately pruritic.
On assessment, you note her rash was consistent with eczema. You would like to prescribe a
topical corticosteroid.

1. What potency should be considered for this patient? Include the frequency of application
and length of recommended treatment.
2. What can be done about her pruritus? Are there any OTC ointments that could be
considered for this patient? Include medication and general patient education in your
discussion.

Overview

Eczema is a chronic inflammatory skin disease that produces dry, itchy skin, rashes, scaly
patches, blisters, and skin infections (National Eczema Association, 2022). Among the different
types of this ailment, atopic dermatitis is the most common. It is most prevalent in children,
although the vast majority of them will outgrow it by the time they reach puberty.

Eczema affects more than 10% of the population in the United States, with 31 million
people suffering from various types and severity of the disease. Healthcare professionals,
dermatologists, and the American Academy of Dermatology (AAD) all recommend moisturizers,
antihistamines, topical steroid creams, and corticosteroids to manage and prevent eczema flare-
ups.

Introduction

Topical corticosteroids are one of the first and most effective therapies for skin conditions
like eczema. They prevent chemical reactions at the cellular level, lowering inflammation, and
hence redness and itching, and enabling the patient to be more comfortable while their skin
recovers. They’re available in a variety of strengths and are classified into seven groups based on
their potency, Class I being the strongest steroid and Class VII as the weakest. They are available
in the market in forms of ointments, creams, lotions, gels, foams, oils, solutions, and shampoos
Long-term usage, a broad area of application, higher potency, and application to areas with
thinner skin all increase the risk of side effects. The amount of corticosteroid administered is
determined by the length of therapy, application frequency, skin location, and total surface area
treated. The fingertip unit approach can be used for application. Topical corticosteroids are used
once or twice daily for three weeks for ultra-high-potency corticosteroids and up to 12 weeks for
high- or medium-potency corticosteroids. Low-potency topical corticosteroids can be used for an
unlimited amount of time (Stacey & McEleney, 2021).

Children frequently require a shorter treatment time and a lower potency steroid. Referral
to a dermatologist is indicated when the diagnosis is ambiguous, normal therapies fail, or allergy
patch testing is not accessible in the healthcare professional's office (Ferrence & Last, 2009).

Discussion

According to studies, individuals with eczema have a mutation in the gene that produces
filaggrin, which is a protein that aids our systems in maintaining a healthy protective barrier on
the skin's very top layer. Moisture can escape and bacteria, viruses, and other pathogens can
enter if there isn't enough filaggrin to establish a robust skin barrier (National Eczema
Association, 2022).

Eczema flare might emerge some time after exposure when looking for probable factors.
Some triggers might be difficult to notice due to the lag period. Everyone is affected differently
by this skin condition. The triggers of one individual may differ from those of another. Its
symptoms may also appear at various times of the year or on different parts of your body.

Common triggers in children include dry skin, sweat, clothes, and food. When skin
becomes excessively dry, it can become fragile, scaly, rough, or tight, triggering an eczema flare-
up. Healthcare professionals should instruct parents to bathe and moisturize their child’s skin
using a thick, fragrance-free moisturizer within 3 minutes after bathing, and more frequently
throughout the day until it feels soft; and dress them in loose-fitting, 100% cotton clothing,
avoiding wool and polyester garments. Also, to launder items in the washing machine using
fragrance- and dye-free laundry detergent and fabric softener. Instead of hanging clothing out to
dry, recommend the use a dryer. Lastly, they should keep their home at comfortable humidity to
prevent their child from sweating.

Certain foods might also cause skin irritation and eczema flare-ups. Parents must make a
list of items that tend to aggravate the eczema, as well as a brief description of what the child ate
and when they noticed a flare. They must be advised to seek immediate medical care after
noticing severe reaction or make an appointment to the physician’s office for a mild reaction.

A particular skin care routine for mild to moderate eczema may be enough to keep the
problem at bay. A topical corticosteroid ointment or cream is also used on the rash if the skin is
irritated and itching. Topical treatments can successfully alleviate irritation and inflammation.
While these medications are beneficial, additional care must be given when selecting and
administering them to children since they are more likely to experience adverse effects. In
general, low-potency topical steroids should be used on children wherever feasible to reduce
risks (More, 2021).

The United States Food and Drug Administration (FDA) has authorized only a few topical
steroids for use in the young age. While there are several more that are often used safely in
children, such as triamcinolone, their usage is still considered off-label. In most circumstances, a
healthcare professional will only use them once all other choices have been exhausted.

Low-potency (Class VII) topical steroid such as Hydrocortisone is commonly used to treat
minor skin irritations such as mild eczema and insect bites in the short term. Topical
hydrocortisone is available in 0.5% to 1% concentrations and in cream and ointment
formulations at the local pharmacy. This medication is available over-the-counter, and are
officially approved for children aged 2 and older, however they can be used in babies under the
supervision of a pediatrician.
Hydrocortisone, are administered to the afflicted parts once or twice daily, ideally soon
after bathing the child. The most frequent method of measuring the quantity of medicine required
is by fingertip unit (FTU). This measurement is exactly what it sounds like: the amount of
medication from the fingertip to the first crease of the finger, which is about 0.5 grams (Ferrence
& Last, 2009; Institute of Quality and Efficiency in Health Care, 2017). After 3-7 days of using
this drug, the child's skin should start to appear improved. This medication is continued until the
irritation has subsided. The therapy might last anywhere from a few days to six weeks. Instruct
parents to discontinue usage if they observe increased redness or rash, stretch marks, darkening
of the skin, or bruising. Any adverse effects or changes in your child's skin, no matter how little,
should always be reported to your healthcare professional.

During steroid therapy, it's helpful to keep applying moisturizing creams on the skin.
Advise parents to wait at least 10 minutes between administering a topical corticosteroid and any
other skin products, to permit drug to be adequately absorbed.

Conclusion and Recommendation

Lilly’s parents or carers must be involved in the planning of treatment for the child. The
healthcare professional should educate them regarding things that could aggravate or trigger their
child’s eczema, including food such as dairy products, eggs, nuts and seeds, soy products, and
wheat; body cleansing products such as soaps, shampoos, and disinfectants that promotes skin
dryness; and clothing materials such as wool and polyester.
To manage flare-ups, they may be prescribed with Hydrocortisone 0.5%-1% cream or
ointment, a low-potency topical steroid and is sold over-the-counter, to lessen skin inflammation
caused by eczema, and so will reduce erythema and itching. Low-potency steroids are
recommended to be used for children and on parts of the body with thinner skin such as the
dorsum of the hands. For Lilly, a dose of 0.25 grams or 0.5 FTU may be appropriate, to be
applied once or twice daily, shortly after bathing. Advise parents to apply the medication at the
same time everyday so that it becomes part of their child's regular routine, which will help them
remember. They may also apply moisturizing creams and lotions 10 minutes after topical steroid
administration. Lilly may be required to use this drug for a few days to six weeks, or until the
symptoms are gone.

Even though certain topical steroids are available over-the-counter, they should be taken
with caution. Use them only if a healthcare expert has advised it and only as indicated. There
may be other choices that may be utilized on a child with eczema that have comparable effects.

References

American Academy of Dermatology Association (2022). Childhood Eczema.

https://www.aad.org/public/diseases/eczema/childhood
Brannon, H. (2021, October). Topical Steroid Strengths: The 7 Drug Classifications.
https://www.verywellhealth.com/steroids-topical-steroid-strengths
Children’s National (2022). Pediatric Eczema (Atopic Dermatitis).
https://childrensnational.org/visit/conditions-and-treatments/allergies-immunology/eczema-
atopic-dermatitis
Ferrence, J. & Last, A. (2009). Choosing Topical Corticosteroids. American Family Physician,
79 (2): 135-140. https://www.aafp.org/afp/2009/0115/p135.html
Institute of Quality and Efficiency in Health Care. (2017, February). Eczema: Steroids and Other
Topical Medications. https://www.ncbi.nlm.nih.gov/books/NBK424899/
McIntosh, J. (2021, July). What to Know About Eczema. Medical News Today.
https://www.medicalnewstoday.com/articles/14417
Medicines for Children (2021). Hydrocortisone (Topical) for Eczema.
https://www.medicinesforchildren.org.uk/medicines/hydrocortisone-topical-for-eczema
More, D. (2021, September). Topical Steroids for Children: Not All Options are Appropriate for
Young Skin. https://www.verywellhealth.com/which-topical-steroids-are-better-for-
children-82741
National Eczema Association (2022). What is Eczema? https://nationaleczema.org/eczema/
Stacey, S. & McEleney, M. (2021). Topical Corticosteroids: Choice and Application. American
Family Physician, 103 (6): 337-343. https://www.aafp.org/afp/2021/0315/p337.html