Treatment for Facial Eczema
Topical corticosteroids are the mainstay of treatment for facial eczema, using the least potent preparation required to control symptoms, applied no more than twice daily. 1, 2
First-Line Treatment
- Apply topical corticosteroids as the primary treatment, using the least potent preparation that effectively controls the eczema 1
- Use mild to moderate potency corticosteroids for facial eczema due to the thinner skin in this area, which increases risk of side effects 1, 3
- Apply treatment no more than twice daily, as once-daily application of potent corticosteroids is equally effective as twice-daily application 2, 3
- Regular bathing is beneficial for cleansing and hydrating the skin, with emollients applied immediately after bathing to provide a surface lipid film that retards evaporative water loss 2
- Use a dispersible cream as a soap substitute instead of regular soaps and detergents that remove natural skin lipids 2
- Avoid extreme temperatures and irritant clothing (such as wool), with cotton clothing being preferred 2
- Keep nails short to minimize damage from scratching and reduce risk of secondary infection 2
Management of Secondary Infections
- Treat overt secondary bacterial infections with appropriate antibiotics; flucloxacillin is usually most appropriate for Staphylococcus aureus, phenoxymethylpenicillin for β-hemolytic streptococci, and erythromycin for penicillin-allergic patients 1, 2
- For herpes simplex infection (eczema herpeticum), administer oral acyclovir early in the disease course; in ill, feverish patients, acyclovir should be given intravenously 1, 2
Second-Line Treatment Options
- Consider ichthammol (1% in zinc ointment) for lichenified eczema, as it is less irritant than coal tars 1
- Coal tar solution (1% in hydrocortisone ointment) is generally preferred to crude coal tar and does not cause systemic side effects unless used extravagantly 1
- Sedating antihistamines can be useful as a short-term adjuvant to topical treatment during relapses with severe pruritus, primarily for their sedative properties 1, 2
- Non-sedating antihistamines have little to no value in treating facial eczema 1, 2
- Topical calcineurin inhibitors (tacrolimus 0.1% and pimecrolimus) can be considered as alternatives to topical corticosteroids, especially for sensitive areas like the face 4, 5
- When using pimecrolimus (Elidel), be aware that it should not be used on malignant or pre-malignant skin conditions and bacterial or viral infections at treatment sites should be resolved before starting treatment 6
Third-Line Treatment Options
- Consider phototherapy for moderate to severe eczema not responding to first-line treatments 1, 7
- Systemic corticosteroids have a limited but definite role in tiding occasional patients with severe atopic eczema, but should not be considered for maintenance treatment until all other avenues have been explored 1
- Newer medications like Janus kinase inhibitors (ruxolitinib, delgocitinib) have shown effectiveness in recent studies but may not be first-line options 5
Important Considerations and Precautions
- Potent and very potent topical corticosteroids should be used with caution on the face and for limited periods only due to increased risk of skin thinning 1, 8
- Long-term studies (up to 5 years) suggest intermittent use of mild/moderate potency topical corticosteroids results in little to no difference in skin thinning, growth abnormalities, or other adverse effects 8
- Patient education is crucial as many patients have unwarranted fears about topical corticosteroids (corticosteroid phobia), which can lead to undertreatment 9
- For maintenance therapy after clearing of active eczema, consider weekend (proactive) therapy with topical corticosteroids, which can significantly reduce the likelihood of relapse compared to reactive treatment 3