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Solomon Behar, MD and Danelle Fisher, MD

Sol Behar and Dr. Fisher discuss the most common skin conditions in children and basic approaches to management.


  • First line management of atopic dermatitis includes good skin hygiene and topical moisturizers; topical corticosteroids are often needed to control flares as well as help with relapses.

  • Topical calcineurin inhibitors are used as second line treatment in children older than 2 years of age.

  • Topical corticosteroids come in varying potencies and formulations and should be tailored to the specific clinical situation.

  • Atopic Dermatitis (AD).  AD is one of the most common skin findings in the pediatric population.  AD can present in early infancy and with varying clinical presentation.

    • In infancy, AD starts on the face, usually on the cheeks; as children age, AD starts to move from extensor  to  flexor surfaces of the inner elbow, knee and even wrist creases.

    • At about one year or older, dry skin can be seen throughout the body.

    • The classic presentation of AD is a rash that is red, dry, scaly and rough to the touch.

      • Areas of dry skin can also be pruritic; pruritus leads to scratching and further skin breakdown, as well as inflammation.

    • AD can also present at the hairline, and should be distinguished from seborrheic dermatitis.

      • The classic presentation of seborrhea is a yellowish, greasy, scaly looking rash that can also be present in the diaper area.

    • Nummular eczema appear as coin-like plaques, usually in the extremities.

      • In infants and toddlers, lesions may appear on the buttocks.

      • Nummular eczema should be distinguished from tinea corporis, which appears with a more raised border with central clearing.

    • Dyshidrotic eczema is generally found on the fingers, palms and soles and is seen in teenagers and adults.

    • Preventative care of AD includes bathing for a short period (< 5 min) of time using warm water and using hypoallergenic soaps and moisturizers.  That is, they should be dye-free, fragrance-free, and non-comedogenic.

      • Some readily available brands in the U.S. include Cetaphil, Aveeno, Eucerin, CeraVe, Aquaphor and Vaseline.

      • Cream formulations are preferred and should be applied as soon as the child is out of the bath; moist skin helps to trap the topical emollient and aid in its efficacy.  Proper application includes making the child “as greasy as possible”.

      • Topical emollients should ideally be applied at least two times per day, and up to 5 times/day.

Editor’s Note:  Topical moisturizers are used to attack the xerosis found in AD.  Emollients (ex. glycol) lubricate and soften skin, occlusive agents (ex. petrolatum) form a layer to retard evaporation of water and humectants (ex. urea) attract and hold water.  Understanding the mechanisms may be helpful in determining which moisturizer to recommend.

Eichenfild L, A, et al. Guidelines of care for the management of atopic dermatitis with topical therapies. J Am Acad Derm. 2014 July;71(1):116-132. PMID: 4326095

  • For the pruritic component, diphenhydramine (0.5-1 mg/kg/dose every 6 hours) or hydroxyzine (0.5-1 mg/kg/dose every 6 hours) can be used .  Over time, patients can develop a tolerance to diphenhydramine and should be cautioned about this.

    • Both medications can cause drowsiness.

    • Covering pruritic areas with loose, cotton clothing can also be helpful and serve as a barrier to scratching.

  • For inflammation, AD flares and prevention of relapses, topical corticosteroids (TCS) are used.  Starting at the lowest potency is recommended.   

    • Hydrocortisone 1% is available over the counter, without a prescription.  It can be used on the body and/or face for mild flares.

  • As needed, increase the potency of the steroid in a stepwise fashion.  Going next to a medium potency steroid.  

    • Triamcinolone is an example of a mid-potency steroid that comes in a wide variety of concentrations.

  • If mid-potency steroids have failed, the next line is a high-potency steroid and generally consultation with a dermatologist.

    • The topical steroid is applied twice a day to the red, raw areas during acute flares. Using topical steroids on the face, a place where the skin is more thin, varies with comfort of the clinician and these areas should be monitored for adverse skin changes.

  • TCS come in cream, ointment, foam and lotion preparations.  Generally, creams are less potent than lotions which are less potent than ointments.  Fisher tends to use ointments.

Editor’s Note: There is a lack of data regarding the most effective TCS regimen for active disease and preventing flares.  Some actually use a short burst of a high-potency steroid to control active disease and then quickly taper in potency.  Others use the regimen suggested above.  A table outlining the relative potencies of TCS can be found in the link below.

For acute flares, the use of TCS is recommended every day until the inflammatory lesions are improved.  Newer studies suggest that after the acute flare has resolved, scheduling the application of a TCS once or twice a week to particular locations of hard to treat skin can reduce relapse.

Eichenfild L, A, et al. Guidelines of care for the management of atopic dermatitis with topical therapies. J Am Acad Derm. 2014 July;71(1):116-132. PMID: 4326095

  • If a patient is still not responding to high-potency steroids, topical calcineurin inhibitors (TCI), tacrolimus ointment and pimecrolimus cream, are used when children fail first line therapies.  FDA has approved these topical therapies for children older than 2 years.

  • TCIs are applied twice daily during acute flares.

  • The TCI black box warning should be discussed with patients before use with note that while rare cases of malignancy have been reported, a causal relationship has not been established.

Editor’s Note: Interestingly, calcineurin inhibitors do not carry a risk of cutaneous atrophy.  Intermittent, application of TCIs 2 to 3 times per week to recurrent sites of disease has also been shown to reduce relapses.

Eichenfild L, A, et al. Guidelines of care for the management of atopic dermatitis with topical therapies. J Am Acad Derm. 2014 July;71(1):116-132. PMID: 4326095

  • Children with AD are predisposed to skin infections.  Bacterial superinfection with Staphylococcus aureus, because it colonizes skin, is frequently seen and responds well to oral antibiotics.  Superinfection should be suspected in skin that appears oozy and weepy.

    • Honey-colored crusting is seen in Impetigo.

    • Eczema herpeticum is painful and appears with umbilicated vesicles that can look like punched out erosions, sometimes in confluent areas.  These too can be large, crusted and occur in follicular areas such as the hairline.

    • Bacterial superinfection can also occur in patients with eczema herpeticum.

    • Viral culture and HSV PCR (more sensitive and more expensive) can be used to isolate HSV-1.

    • These patients should be treated promptly with IV acyclovir for 5-10 days as well as oral anti-staphylococcal , such as cephalexin, owing to the common occurrence of bacterial superinfection.  Consider using  a different agent to cover for methcillin resistant staph aureus (MRSA) if their are high rates of MRSA infection in your geographic area.

  • Contact Dermatitis occurs when the skin has touched an irritant.  It is a delayed, type IV hypersensitivity reaction.

  • Think about this diagnosis if a child has a pruritic rash in an interesting distribution; for example if the irritant is sunscreen the rash may appear on the upper chest and back in areas where the sunscreen was applied.  Of, if a child has been exposed to poison oak or poison ivy it may appear on the extremities.

  • To treat poison ivy or poison oak, make sure to wash the irritated skin will as the toxin can live on fomites.  Systemic steroids (prednisone, 2 mg/kg/day divided BID) are used for severe cases and generally administered for 3 to 5 days.

  • Low potency TCS and oral antihistamines may also help with immediate relief of pruritus.

  • Nickel dermatitis is another common contact dermatitis as nickel can be found in necklaces, bracelets, earrings, belts, snaps.

  • In addition to TCS, one can recommend painting these surfaces with clear nail polish to prevent further skin irritation.

  • Phytophotodermatitis is a blistering, painful pruritic dermatitis that is activated by sunlight; a classic story is a child or caregiver who has touched a lemon or lime (as these fruits contain psoralen) and then goes into the sun.  The reaction typically begins within 24 hours of exposure.

  • It may mimic abuse as it may be in the shape of a hand on a child’s body.

  • Treatment is with TCS and antihistamines.