Topical Corticosteroid Use in Infants and Young Children

Introduction to Risks

• Infants and young children (0-2 years) are at highest risk of growth impairment with systemic absorption of topical corticosteroids due to their higher body surface area-to-weight ratio, thinner skin barrier, and immature drug metabolism pathways 1

Adverse Effects

• Long-term continuous use of topical corticosteroids can lead to skin atrophy, and application on large body surface areas or thin skin areas (face, genitals, intertriginous areas) can increase absorption through damaged skin barrier, potentially causing local adverse effects such as striae, purpura, hypopigmentation, and hypertrichosis 2
• Systemic adverse effects of topical corticosteroids include hypothalamic-pituitary-adrenal axis suppression, growth impairment in children, and potential associations with cataracts, glaucoma, and diabetes 2
• Monitor for adverse effects such as skin atrophy, telangiectasia, striae, and contact hypersensitivity, which occurs in 2-5% of patients, with a moderate strength of evidence 3

Classification and Potency

• Topical corticosteroids are classified into potency levels, with examples including:

Treatment Guidelines

• The fundamental principle of using topical corticosteroids is to use the least potent steroid necessary to control the disease, with the goal of discontinuing them for short periods to minimize adverse effects while maintaining therapeutic efficacy, as suggested by the BMJ 5
• Short-term use (2-4 weeks) of topical corticosteroids is recommended to avoid adverse effects, with a moderate strength of evidence 3
• Topical corticosteroids should be applied twice daily for optimal effect, with a high strength of evidence, and tapered as improvement occurs 3
• The American Academy of Dermatology recommends using the lowest potency corticosteroid possible for the shortest duration necessary to minimize adverse effects in pediatric populations 6
• For atopic eczema, the British Medical Journal recommends using the least potent preparation required to control symptoms 5
• Mid-potency (Class 3-4) topical corticosteroids are preferred for initial treatment of stasis dermatitis on the legs, with a moderate strength of evidence 3, 7

Application and Dosage

• The amount of hydrocortisone to apply can be measured using the "finger tip unit", with appropriate amounts for a 2-week treatment period including:

• Creams are preferred for weeping or oozing lesions, intertriginous areas, and when cosmetic acceptability is important, while ointments are preferred for dry, lichenified lesions, and lotions/solutions are preferred for hairy areas like the scalp 2, 8

Alternative Treatments

• The American Academy of Dermatology recommends considering alternatives such as tacrolimus 0.1% for facial and genital psoriasis 6
• Pimecrolimus may be considered for sensitive areas in atopic dermatitis 9
• Calcineurin inhibitors, such as tacrolimus 0.1%, may be effective for patients who cannot tolerate steroids, with a low strength of evidence 3
• Topical calcineurin inhibitors, such as pimecrolimus 1% cream and tacrolimus 0.1% ointment, are effective alternatives for facial seborrheic dermatitis, particularly useful for maintenance therapy or when steroids are contraindicated 5

Special Considerations

• For children, the lowest potency and shortest duration possible should be used, with consideration of alternatives like calcineurin inhibitors for prolonged facial use 2, 10
• The American Academy of Dermatology recommends using a Class V/VI corticosteroid for facial applications, with more severe reactions requiring consultation with dermatology before using higher potency steroids 10
• The National Institute for Health and Care Excellence suggests using the lowest effective potency of topical corticosteroids and limiting the duration of use to minimize adverse effects, particularly on the face 10