What is a good cream to apply for itching, redness, and rash, and a suitable facial wash, for a patient previously treated with Sarno (coal tar) cream?

Management of Facial Rash with Itching and Redness

For a patient with facial itching, redness, and rash previously treated with coal tar cream (Sarno), I recommend switching to hydrocortisone 1% cream for treatment and using a gentle, soap-free cleanser for facial washing.

Recommended Treatment Plan

Topical Treatment

1. Hydrocortisone 1% cream

   • Apply to affected areas 2-3 times daily for 1-2 weeks 1
   • Hydrocortisone 1% is specifically recommended for facial dermatitis due to its low potency and minimal risk of skin atrophy 2
   • Do not use more than 3-4 times daily 1

2. Alternative options if hydrocortisone is ineffective after 2 weeks:

   • Topical calcineurin inhibitors:
     • Tacrolimus 0.03% or 0.1% ointment 2
     • Pimecrolimus 1% cream for mild-to-moderate dermatitis 2
   • These are steroid-sparing alternatives particularly suitable for facial use

Facial Cleanser Recommendations

• Gentle soap-free cleanser
  • Use lukewarm (not hot) water
  • Pat dry gently rather than rubbing 2
  • Choose fragrance-free, preservative-free formulations 2

Moisturizing

• Apply emollients or moisturizers frequently throughout the day
• Apply at least 15-30 minutes before or after steroid application 2
• Choose fragrance-free, preservative-free formulations in tubes rather than jars

Rationale for Treatment Selection

Why Hydrocortisone 1% Cream?

• Specifically indicated for facial rashes, inflammation, and itching 1
• Safe for facial use due to low potency 2
• FDA-approved for treating itching associated with eczema, seborrheic dermatitis, and other skin irritations 1
• Low risk of side effects compared to higher-potency steroids

Why Change from Coal Tar?

• Coal tar products are often poorly tolerated due to:
  • Cosmetic issues (especially important for facial use)
  • Staining of clothes
  • Strong odor
  • Potential for irritant contact dermatitis
  • Photosensitivity to UVA 3
• While coal tar has been used for over 100 years for psoriasis and other skin conditions 4, it's less commonly used now, especially for facial application

Monitoring and Follow-up

• Assess response after 2 weeks of treatment
• If no improvement is seen after 2 weeks of appropriate treatment, consider:
  • Referral to dermatology for patch testing 2
  • Switching to a calcineurin inhibitor like tacrolimus or pimecrolimus 2
  • Evaluating for possible secondary bacterial infection

Important Considerations

• Avoid potential irritants:

  • Harsh soaps
  • Detergents
  • Fragrances
  • Hot water 2

• Avoid topical antihistamines as they may increase the risk of contact dermatitis 2

• For severe itching: Consider short-term oral antihistamines, particularly sedating ones at night if sleep is disturbed 2

• If secondary infection is suspected: Consider appropriate antibiotics based on clinical presentation 2

Special Considerations for Non-Steroidal Options

If the patient prefers a non-steroidal approach or has contraindications to steroids, consider:

• Non-steroidal facial creams containing ingredients like zinc PCA, piroctone olamine, and stearyl glycyrrhetinate, which have shown efficacy for facial seborrheic dermatitis 5

• Calcineurin inhibitors (tacrolimus 0.03% or pimecrolimus 1%) which are effective steroid-sparing alternatives 2