Current practice parameters recommend treatment options to both prevent eczema flare-ups and manage symptoms in infants and toddlers. The following section provides guidance on several topics for shared decision-making with caregivers:

• Moisturizers
• Baths
• Prescription moisturizers
• Corticosteroids
• Topical calcineurin inhibitors
• Wet wraps
• Bleach baths

Preventative Care

The following recommendations can be used to prevent eczema flare-ups and worsening of symptoms in infants and toddlers.

Moisturizers

The best preventive care for Atopic Dermatitis is moisturization, as it enhances the skin barrier to protect from allergens, pathogens, and injury while also reducing water loss, which can predispose skin damage. The recommendation for caregivers is to:

• Apply fragrance-free, thick-texture moisturizer with low water content daily, especially after bath, shower, or hand washing.
• Apply moisturizer at least daily, especially within 3 minutes after bathing, to lock in the moisture. Waiting too long after bathing can dry out a child’s skin.
• Wash hands before applying the moisturizer, to avoid trapping any allergens or germs that may be on hands against the child’s skin.
• Use moisturizers that are fragrance- and dye-free, as they will be less irritating on the baby’s skin.

Soak and Seal Method

Daily short baths with lukewarm water and gentle cleaners, with an emphasis on moisturizer immediately after, is the most common pediatric dermatologist recommendation for patients with eczema. The recommendations for caregivers are:

• The child should be given short bath of about 10-15 minutes daily in lukewarm water with gentle cleanser.
• The caregiver should gently pat (not rub) off the water using a towel and leave the skin slightly damp.
• Topical steroids or medications should be applied as prescribed after the bath.
• Moisturizer should then be applied all over the body, within 3 minutes. The moisturizer should be absorbed into the skin before clothes are placed on the child.

Topical Treatment – Corticosteroids

Topical steroids are effective in the treatment of eczema. For patients with uncontrolled AD refractory to moisturization alone, the addition of a topical corticosteroid (TCS) is strongly recommended. If topical steroids are needed, recommend applying 1-2 times a day for 7 days on active lesions and continue application for 2-3 days after eczema lesions have resolved. (3)

• Wet wraps
  • Wet wrap therapy can be useful for eczema flares (1)
  • After the bath, caregivers should apply moisturizers, moisten clean clothes or gauze, and wrap the affected areas on the patient
  • Apply for 4-7 days for minimum of 1 hour to maximum overnight once per day

Non-topical treatment – Bleach Baths

Dilute bleach baths are conditionally recommended for patients with moderate-severe AD in addition to topical therapy. (3) In children with moderate to severe eczema, bleach baths may reduce the severity (1). Use unconcentrated household bleach. Fill a bathtub with lukewarm water (about 40 gallons) and add 1/2 cup of bleach. Have the child soak for 10 minutes and then rinse off fully with warm tap water and continue with the child’s skincare routine. Before making this recommendation, consider:

• How these baths will fit into routine
• Used as an adjunct to otherwise good skin care
• Provisions are clear and written instructions provided
• The extent of open skin (cracks, fissures, excoriations) may make bleach baths less tolerable to some patients 
• Likely to see effects in AD severity within 4 weeks
• Conditional due to low certainty of benefits and potential harms with open skin

Non-topical treatment – Elimination diet

Elimination Diets with or without skin testing is conditionally NOT recommended with AD compared with an unrestricted diet. (3) When brought up by a caregiver, consider:

• Young age of patient and risk factors for developing IgE-mediated food allergy favor against pursuing elimination diet
• Risk for malnutrition
• This carries a high risk of false-positive results, which may lead to unnecessary dietary restriction in sensitized but asymptomatic infants, subsequently increasing the risk of developing a true IgE-mediated food allergy.
• Those who pursue this provide strategies to mitigate harm; what managing a food allergy entails and scheduling close follow-up (w/i 4 weeks)

Treatments requiring referral

Allergen Immunotherapy, Systemic treatments, and Narrow-band UV-B light (3)

References

1. Bakaa L, Pernica JM, Couban RJ, et al. Bleach baths for atopic dermatitis: A systematic review and meta-analysis including unpublished data, Bayesian interpretation, and GRADE. Ann Allergy Asthma Immunol. 2022;128(6):660-668.e9. doi:10.1016/j.anai.2022.03.024
2. Northwestern Medicine. (n.d.). Infant Atopic Dermatitis Severity Scorecard: vIGA-ADTM with examples. iREACH Training Materials (Early Peanut Product Introduction Tools for Pediatric Clinicians. https://www.feinberg.northwestern.edu/sites/cfaar/docs/Pediatric%20Clinician%20Atopic%20Dermatitis%20Severity%20Scorecard2.pdf
3. Chu, D. K., Schneider, L., Asiniwasis, R. N., Boguniewicz, M., Casale, T. B., Chu, A. W. L., Eigenmann, P. A., Fleischer, D. M., Greenhawt, M., Horner, C. C., Mack, D. P., Milner, J. D., Oppenheimer, J., Schneider, A. T., Searing, D. A., Spergel, J. M., Stukus, D. R., Venter, C., Wang, J., … Golden, D. B. K. (2024). Atopic dermatitis (eczema) guidelines: 2023 American Academy of Allergy, Asthma and Immunology/American College of Allergy, Asthma and Immunology Joint Task Force on Practice Parameters GRADE- and Institute of Medicine-based recommendations. Annals of Allergy, Asthma & Immunology, 132(3), 274–312. https://doi.org/10.1016/j.anai.2023.11.009