Initial Treatment for Dermatitis on Face and Chest
For dermatitis affecting the face and chest in adults, start with emollients/moisturizers applied liberally and use the least potent topical corticosteroid necessary to control inflammation—typically a mild-to-moderate potency steroid for facial involvement—applied no more than twice daily. 1, 2
First-Line Treatment Algorithm
Step 1: Establish Baseline Care
- Moisturizers: Apply liberally and frequently throughout the day 1, 2
- Gentle cleansing: Use soap-free cleansers; avoid traditional soaps that strip natural skin lipids 3
- Bathing: Daily bathing is conditionally recommended, followed immediately by moisturizer application 1
Step 2: Topical Corticosteroids (Primary Anti-Inflammatory)
The basic principle is to use the least potent preparation required to keep the eczema under control 3
For face and chest dermatitis:
- Facial areas: Use mild-to-moderate potency topical corticosteroids (e.g., 1% hydrocortisone) due to thinner, more sensitive skin 3
- Chest areas: Can tolerate moderate potency steroids
- Application frequency: No more than twice daily 3
- Duration: Use for short periods when possible, with intermittent breaks 3
Important caveat: Very potent and potent steroids should be used with caution on the face for limited periods only, as the main risk is pituitary-adrenal axis suppression, particularly concerning in children but relevant for all patients 3
Step 3: Consider Topical Calcineurin Inhibitors as Steroid-Sparing Agents
If concerned about steroid side effects on facial skin or for maintenance therapy:
- Tacrolimus 0.03% or 0.1% ointment (strong recommendation) 1, 2
- Pimecrolimus 1% cream for mild-to-moderate disease (strong recommendation) 1, 2
These are particularly useful for facial dermatitis where long-term steroid use raises concerns about skin atrophy. They can be used in conjunction with topical corticosteroids 4.
Step 4: Adjunctive Treatments for Specific Symptoms
For severe pruritus during flares:
- Sedating antihistamines at bedtime only (not daytime use) 3
- Non-sedating antihistamines have little to no value 3
- Note: Topical antihistamines are conditionally recommended against 1
For signs of secondary bacterial infection (crusting, weeping):
- Flucloxacillin for Staphylococcus aureus (most common pathogen) 3
- Erythromycin if penicillin allergy or resistance 3
- Consider dilute bleach baths for moderate-to-severe disease with clinical infection signs 1
Newer Treatment Options (If First-Line Inadequate)
For mild-to-moderate disease not responding adequately:
- Crisaborole ointment (PDE-4 inhibitor) - strong recommendation 1
- Ruxolitinib cream (topical JAK inhibitor) - strong recommendation 1
Common Pitfalls to Avoid
Steroid phobia: Many patients undertreated due to unfounded fears. Explain that appropriate-potency steroids used correctly are safe and effective 3
Over-potent steroids on face: Avoid very potent/potent steroids on facial skin except for very limited periods under specialist guidance 3
Inadequate moisturizer use: Emollients are most effective when applied immediately after bathing to trap moisture 3
Treating without infection control: If crusting/weeping present, bacterial infection must be addressed concurrently 3
Continuous steroid use without breaks: When possible, stop corticosteroids for short periods to minimize systemic effects 3
When to Refer to Specialist
Refer if 3:
- Failure to respond to mild-potency steroids (children) or moderate-potency steroids (adults)
- Diagnostic uncertainty
- Need for second-line treatments
- Suspected contact dermatitis complicating atopic dermatitis
Maintenance Strategy
Once acute inflammation controlled:
- Intermittent topical corticosteroids: Medium-potency steroids 2 times per week to reduce flares (strong recommendation) 1
- Continue daily emollients
- Identify and avoid specific triggers (irritants, temperature extremes) 3
Most people with eczema will respond well to this first-line management approach and do not require specialist referral 3.