What is the recommended treatment for facial eczema?

Treatment of Facial Eczema

Topical corticosteroids are the mainstay of treatment for facial eczema, using the least potent preparation required to control symptoms, applied once or twice daily for short periods. 1

First-Line Treatment Approach

Topical Corticosteroids

• Potency selection for face:
  • Use mild potency (1% hydrocortisone) for facial eczema initially
  • Apply once or twice daily for short periods (typically 1-2 weeks)
  • Avoid very potent or potent preparations on the face due to increased risk of skin thinning
  • The basic principle is to use the least potent preparation required to keep eczema under control 1

Application Method

• Apply a thin layer only to affected areas
• Treatment should not be applied more than twice daily (once daily application is often sufficient) 1, 2
• Apply after bathing when skin is dry for best absorption 1
• When possible, corticosteroids should be stopped for short periods to minimize side effects 1

Emollients

• Essential adjunctive therapy to corticosteroids
• Apply regularly to maintain skin hydration
• Most effective when applied after bathing 1
• Can be used as soap substitutes (dispersible creams) for cleansing 1

Second-Line Options

Topical Calcineurin Inhibitors (TCIs)

• Pimecrolimus (Elidel) cream can be considered for facial eczema when corticosteroids are not appropriate
• Important safety considerations with pimecrolimus:
  • Not for continuous long-term use
  • Not for use in children under 2 years old
  • Should not be used on infected skin 3
  • May cause local symptoms such as skin burning or stinging, especially in first few days 3

Tar Preparations

• Ichthammol (1% in zinc ointment) is less irritant than coal tar and may be suitable for facial application
• Coal tar solution (1%) may be combined with hydrocortisone ointment 1

Managing Complications

Secondary Infection

• Treat bacterial infections with appropriate antibiotics:
  • Flucloxacillin for Staphylococcus aureus (most common)
  • Phenoxymethylpenicillin for β-hemolytic streptococci
  • Erythromycin for penicillin-allergic patients 1
• For eczema herpeticum (viral infection):
  • Oral acyclovir early in course of disease
  • Intravenous acyclovir for ill, feverish patients 1

Severe Itch Management

• Sedating antihistamines may help with severe pruritus as short-term adjuvant therapy
• Best used at night to help with sleep disturbance
• Non-sedating antihistamines have little value in eczema 1

Special Considerations for Facial Eczema

• Avoid occlusive dressings on the face unless specifically directed by a specialist
• For recalcitrant facial eczema in children, hydrocolloid dressings (as face masks) may be considered 4
• Facial skin is thinner and more prone to side effects from topical corticosteroids
• Minimize sun exposure during treatment, especially with calcineurin inhibitors 3

Common Pitfalls to Avoid

1. Undertreatment due to steroid phobia - Important to explain benefits and risks of topical corticosteroids to patients/parents 1
2. Prolonged use of potent steroids on the face - Can lead to skin thinning and other local adverse effects
3. Failure to treat secondary infections - Can lead to treatment failure and worsening of eczema
4. Overuse of antihistamines - Value may be reduced due to tachyphylaxis 1
5. Neglecting basic skin care - Emollients and avoiding irritants are fundamental

When to Refer to a Specialist

• Diagnostic uncertainty
• Failure to respond to appropriate first-line treatment
• Severe or widespread eczema
• Recurrent secondary infections
• When considering second-line treatments 1

The evidence suggests that intermittent use of mild to moderate potency topical corticosteroids for facial eczema is generally safe and effective when used appropriately 5. For children with mild to moderate eczema, short bursts of treatment appear to be as effective as prolonged use 6.