First-Line Treatment for Eczema Flare on the Face
For an eczema (atopic dermatitis) flare on the face, the first-line treatment is a mild-potency topical corticosteroid applied twice daily for a short duration, along with regular use of emollients. 1
Treatment Algorithm for Facial Eczema
Step 1: Initial Assessment and Treatment
- Assess severity: Note extent, location, and presence of crusting or weeping (which may indicate infection)
- First-line therapy:
- Apply a mild-potency topical corticosteroid (e.g., 1% hydrocortisone) to affected areas twice daily
- Use for a limited period (typically 1-2 weeks for facial flares)
- Apply emollients liberally throughout the day as a soap substitute and moisturizer
Step 2: Bathing and Skin Care
- Use dispersible cream as a soap substitute to cleanse the skin
- Apply emollients immediately after bathing to lock in moisture
- Avoid irritants such as harsh soaps, detergents, and wool clothing
- Keep nails short to minimize damage from scratching
Step 3: Managing Specific Concerns for Facial Eczema
- Caution: The face is particularly susceptible to steroid-induced side effects
- Avoid potent or very potent steroids on facial skin
- Do not use occlusive dressings on the face
- Monitor for signs of skin thinning
- Alternative for steroid-sensitive areas: Consider topical calcineurin inhibitors (TCIs) such as pimecrolimus cream 1% if topical steroids are not advisable 2
Evidence for Treatment Recommendations
Topical corticosteroids remain the mainstay of treatment for eczema flares 1, 3. For facial eczema specifically, mild-potency corticosteroids are preferred due to the thinner skin and higher risk of adverse effects in this area. The British Association of Dermatologists guideline emphasizes that preparations in the potent and very potent categories should be used with caution and for limited periods only 1.
A Cochrane review found that once-daily application of potent topical corticosteroids is likely as effective as twice-daily application 4, but this may not apply to mild-potency steroids typically used on the face.
Maintenance and Flare Prevention
After the acute flare resolves, consider a proactive approach to prevent recurrence:
- Continue daily emollient use
- Consider twice-weekly application of topical corticosteroids to previously affected areas (weekend therapy or "proactive approach")
Safety Considerations
The risk of adverse effects from topical corticosteroids on the face is higher due to thinner skin. However, a systematic review of long-term topical corticosteroid use found only one episode of skin atrophy among 1,213 patients using mild/moderate potency steroids intermittently over five years 5. This suggests that when used appropriately, the risk of skin thinning is low.
When to Consider Second-Line Treatments
If first-line treatment fails or is contraindicated, consider:
- Topical calcineurin inhibitors (pimecrolimus for mild-moderate eczema) 2, 3
- Referral to a specialist if:
- Diagnostic uncertainty exists
- No response to mild-potency steroids
- Secondary infection is present (requiring antibiotics)
- Eczema is severe or significantly impacts quality of life 1
Common Pitfalls to Avoid
- Undertreatment: Fear of steroid side effects often leads to inadequate treatment
- Overtreatment: Using potent steroids on facial skin for prolonged periods
- Neglecting emollients: These are essential both during flares and for maintenance
- Missing infections: Secondary bacterial (usually S. aureus) or viral (herpes simplex) infections require specific treatment
- Ignoring triggers: Failure to identify and address environmental or allergic triggers
Remember that most patients with eczema will respond well to first-line management and do not require specialist referral when treatment is applied correctly and consistently.