Clinical Takeaways
- Topical steroids are the mainstay of treatment for inflammatory skin disorders in pediatric patients. Off‑label use is common, reflecting limited pediatric‑specific labeling rather than lack of clinical utility.
- Children are more susceptible to adverse effects from topical steroids because of thinner skin and increased surface area-to-mass ratio. Newborns and infants are at the highest risk of systemic absorption. Adverse effects, including skin atrophy, striae, telangiectasia, perioral dermatitis, and rare systemic effects such as hypothalamic-pituitary-adrenal (HPA) axis suppression, are most strongly associated with excessive potency, prolonged duration, occlusion, and treatment of large surface areas.
- Steroid selection in pediatrics must be stratified by age, anatomic site, disease severity, and treatment duration to prevent adverse effects.
- Shorter durations should be used in children than in adults.
- Use the lowest-strength corticosteroid that will clear the dermatitis in a short amount of time. If long-term therapy is required, intermittent therapy is recommended over continuous therapy.
- In infants, treatment should be restricted almost exclusively to low‑potency topical steroids, applied sparingly and for short durations. Use on the face, neck, intertriginous areas, and diaper region warrants particular caution because occlusion and local warmth further increase absorption. Only low-potency topical corticosteroids should be used in the diaper area, except for brief, closely supervised courses of mid-potency steroids in severe or refractory disease.
- In toddlers and young children, mild disease is typically managed with low‑potency agents. For moderate inflammatory dermatoses, short courses of mid‑potency agents may be used on the trunk and extremities. Higher‑potency agents may be appropriate for severe flares but should be limited in duration and avoided on sensitive skin sites. Toddlers and children requiring mid- to high-potency topical corticosteroids require regular evaluations and patient and/or parental education.
- Adolescents physiologically resemble adults in terms of skin barrier function and may safely tolerate a wider range of topical corticosteroid potencies. Low‑ and mid‑potency agents remain first‑line for facial, flexural, or mild disease, while higher‑potency steroids may be used for short courses on thick, lichenified plaques of the trunk or extremities. Despite increased tolerance, adolescents remain at risk for steroid misuse, particularly with prolonged unsupervised use, underscoring the importance of counseling and defined treatment durations.