What is the next best treatment for facial eczema unresponsive to moderate potency topical corticosteroids (steroids)?

Treatment for Facial Eczema Unresponsive to Moderate Potency Topical Corticosteroids

For facial eczema that has not responded to moderate potency topical corticosteroids, topical calcineurin inhibitors such as pimecrolimus cream 1% should be used as the next treatment option.

Understanding the Treatment Challenge

Facial eczema presents unique treatment challenges because:

• The facial skin is thinner and more susceptible to steroid-related adverse effects
• Continued use of moderate potency steroids risks local side effects like skin atrophy, telangiectasia, and striae
• The face is a visible area where both disease control and avoiding side effects are important for quality of life

Treatment Algorithm

First-line approach for unresponsive facial eczema:

1. Switch to topical calcineurin inhibitors (TCIs):

   • Pimecrolimus cream 1% applied twice daily to affected areas 1
   • TCIs are specifically indicated for patients who have failed topical corticosteroids or when corticosteroids are not advisable 1
   • TCIs do not cause skin atrophy, which is particularly important for facial application

2. If TCIs are not available or contraindicated:

   • Consider a short course (up to 7 days) of low potency (class 6-7) topical corticosteroids 2
   • Avoid using higher potency steroids on the face due to increased risk of adverse effects 3

For severe or persistent cases:

1. Consider short-term oral antihistamines to control pruritus 2

2. Rule out secondary infection:

   • If signs of infection are present, consider adding topical or oral antibiotics
   • Flucloxacillin is usually most appropriate for treating Staphylococcus aureus, the most common pathogen 3

3. For severe, widespread, or debilitating facial eczema:

   • Consider dermatology referral for evaluation for systemic therapy options 2
   • Short-term systemic corticosteroids may be considered in severe cases, but only as a bridge to other therapies 2

Important Considerations

Potency and application:

• Lower potency corticosteroids should always be used on the face and intertriginous areas 3
• Avoid prolonged use (>4 weeks) of any topical corticosteroid on the face 3
• Apply treatments in a thin layer, twice daily or as directed 1, 4

Monitoring for adverse effects:

• Watch for signs of skin atrophy, telangiectasia, and folliculitis with continued steroid use 2
• With TCIs, temporary burning or warmth sensation is common but typically resolves within a few days 1

Patient education:

• Many patients don't understand topical steroid potency classifications, leading to misuse 5
• Clearly explain that TCIs are not steroids and don't cause skin thinning 1
• Emphasize the importance of consistent moisturizing in addition to anti-inflammatory treatments 2

Caveats and Pitfalls

• Avoid using ultrahigh-potency (class 1) corticosteroids on the face, even for short periods, as they carry significant risk of local adverse effects 4
• Do not use occlusive dressings with topical corticosteroids on facial eczema, as this increases absorption and risk of side effects 4
• Be aware that TCIs carry a black box warning regarding theoretical risk of malignancy, though a causal link has not been established 1
• Do not continue ineffective treatments - if no improvement is seen within 2 weeks of any treatment, reassessment of diagnosis may be necessary 4

By following this approach, most cases of facial eczema unresponsive to moderate potency topical corticosteroids can be effectively managed while minimizing the risk of adverse effects.