What is the best treatment for facial atopic dermatitis (eczema)?

From the Guidelines

The best treatment for facial eczema typically involves a combination of gentle skincare and appropriate medications, with a strong recommendation for dupilumab, tralokinumab, upadacitinib, and abrocitinib for moderate to severe cases, as stated in the 2024 guidelines 1. The treatment approach should prioritize gentle skincare, including the use of mild, fragrance-free cleansers and moisturizers applied multiple times daily to maintain skin hydration. For mild cases, over-the-counter 1% hydrocortisone cream can be applied sparingly twice daily for up to 7 days. For moderate to severe cases, prescription topical corticosteroids like triamcinolone 0.1% or fluocinolone 0.025% may be needed, but use these on the face for only 3-5 days due to risk of skin thinning. Non-steroidal alternatives include tacrolimus (Protopic) 0.03% or 0.1% ointment and pimecrolimus (Elidel) 1% cream, which can be used twice daily for longer periods without the side effects of steroids. Avoid known triggers such as harsh soaps, fragrances, extreme temperatures, and stress, as suggested in the management guidelines 1. Keep fingernails short to prevent damage from scratching. If symptoms include severe itching, an oral antihistamine like cetirizine 10mg daily may help. Persistent or severe facial eczema should be evaluated by a dermatologist, as it might require systemic treatments like oral corticosteroids or immunomodulators in some cases, following the recommendations outlined in the 2024 guidelines for the management of atopic dermatitis in adults with phototherapy and systemic therapies 1. Some key considerations in the management of atopic dermatitis include the use of emollients, topical corticosteroids, and the avoidance of provoking factors, as highlighted in earlier guidelines 1. However, the most recent and highest quality evidence supports the use of biologics and JAK inhibitors for moderate to severe atopic dermatitis, as recommended in the 2024 guidelines 1.

Some key points to consider in the treatment of facial eczema include:

• Gentle skincare with mild, fragrance-free cleansers and moisturizers
• Use of topical corticosteroids for short periods, with caution on the face
• Non-steroidal alternatives like tacrolimus and pimecrolimus
• Avoidance of triggers like harsh soaps, fragrances, and extreme temperatures
• Evaluation by a dermatologist for persistent or severe cases
• Consideration of systemic treatments like biologics and JAK inhibitors for moderate to severe cases, as recommended in the 2024 guidelines 1.

In terms of specific medications, the 2024 guidelines recommend:

• Dupilumab for adults with moderate to severe atopic dermatitis
• Tralokinumab for adults with moderate to severe atopic dermatitis
• Upadacitinib for adults with moderate to severe atopic dermatitis who have failed other systemic therapies
• Abrocitinib for adults with moderate to severe atopic dermatitis who have failed other systemic therapies
• Baricitinib, methotrexate, and other systemic therapies may be considered in certain cases, but with careful monitoring and consideration of potential side effects, as outlined in the guidelines 1.

Overall, the treatment of facial eczema should be individualized and based on the severity of symptoms, with a focus on gentle skincare, avoidance of triggers, and the use of appropriate medications, as recommended in the 2024 guidelines 1.

From the FDA Drug Label

CLINICAL PHARMACOLOGY Topical corticosteroids share anti-inflammatory, antipruritic and vasoconstrictive actions. DOSAGE AND ADMINISTRATION Apply triamcinolone acetonide cream USP, 0. 1% as appropriate, to the affected area two to three times daily.

The best treatment for facial eczema is applying triamcinolone acetonide cream USP, 0.1% two to three times daily, rubbing it in gently.

• Key points:
  • Apply to the affected area
  • Rub in gently
  • Two to three times daily
  • May use occlusive dressing for management of recalcitrant conditions, but this should be determined on an individual basis 2 2

From the Research

Treatment Options for Facial Eczema

• Topical anti-inflammatory treatments, such as potent and/or very potent topical steroids, tacrolimus 0.1%, and ruxolitinib 1.5%, are ranked among the most effective treatments for improving patient-reported symptoms and clinician-reported signs of eczema 3
• Janus kinase inhibitors, such as ruxolitinib 1.5% and delgocitinib 0.5% or 0.25%, are also effective in treating eczema 3
• Topical corticosteroids are classified by strength and the risk of adverse effects, and the risk of adverse effects increases with prolonged use, a large area of application, higher potency, occlusion, and application to areas of thinner skin such as the face and genitals 4

Safety of Topical Corticosteroids

• The safety of topical corticosteroids in atopic eczema has been reviewed, and no evidence of harm was found when used intermittently 'as required' to treat flares or 'weekend therapy' to prevent flares 5
• However, long-term safety data are limited, and treatment should be limited to the short term 6
• Local application site reactions are most common with tacrolimus 0.1% and crisaborole 2%, and least common with topical steroids 3

Additional Treatment Considerations

• Proactive therapy with twice weekly use of both topical corticosteroids and calcineurin inhibitors in previously affected areas has been found to reduce the time to the next eczematous flare 7
• Adjunctive treatment options include wet wrap therapy, anti-histamines, and vitamin D supplementation 7
• Systemic antibiotics may be warranted in infected lesions, but empiric antibiotics use in uninfected lesions is controversial 7