What is the best treatment for eczema on the face?

Treatment for Facial Eczema

For facial eczema, the recommended first-line treatment is a low-potency topical corticosteroid such as hydrocortisone 1%, applied once or twice daily, along with regular use of emollients and avoidance of irritants. 1, 2

First-Line Treatment

• Use the least potent topical corticosteroid preparation required to control symptoms, with low-potency agents (Class VII) such as hydrocortisone 1% being most appropriate for facial skin due to its thinner nature and higher risk of side effects 2
• Apply topical corticosteroids once or twice daily (most newer preparations require only once daily application) for the shortest duration needed to control symptoms 3, 2
• Use emollients regularly as soap substitutes and moisturizers, applying them after bathing to provide a surface lipid film that prevents water loss 1
• Avoid soaps and detergents that remove natural skin lipids, using emollient cream as a soap substitute instead 1
• Keep nails short to minimize damage from scratching 1
• Avoid extreme temperatures and irritant clothing (such as wool), with cotton clothing being preferred 1

Precautions for Facial Application

• The face, neck, and body folds are more susceptible to side effects from topical corticosteroids, requiring lower potency preparations 2
• Monitor for signs of skin thinning, telangiectasias, and hypopigmentation, especially with prolonged use 2
• Consider short treatment breaks to minimize potential side effects when possible 2
• Limit application to no more than twice daily, with once daily often being sufficient 3, 2

Second-Line Treatment Options

• For patients concerned about topical corticosteroid side effects, consider topical calcineurin inhibitors such as tacrolimus 0.03% or 0.1% ointment or pimecrolimus 1% cream 2
• Tacrolimus 0.1% ointment has shown greater efficacy than corticosteroid regimens in adults with moderate to severe atopic dermatitis over long-term treatment (6 months), though it may cause more skin burning initially 4
• Ichthammol (1% in zinc ointment) is less irritant than coal tars and particularly useful for lichenified eczema 1
• Antihistamines are primarily valuable for their sedative properties during severe pruritic episodes and are useful as short-term adjuvants to topical treatment during relapses with severe itching 1

Management of Infection

• Antibiotics are important for treating overt secondary bacterial infection, with flucloxacillin usually being most appropriate for Staphylococcus aureus 3, 1
• For penicillin allergy, erythromycin is recommended 3
• Herpes simplex infection (eczema herpeticum) requires oral acyclovir early in the disease course 1

Long-Term Management

• For maintenance therapy between flares, intermittent use of topical corticosteroids (twice weekly) is recommended to reduce disease flares and relapse 2
• Evidence from long-term studies (up to 5 years) suggests that intermittent use of mild to moderate potency topical corticosteroids results in little to no difference in skin thinning or growth abnormalities 5
• Consider referral to a specialist if there is treatment failure, extensive disease, or diagnostic uncertainty 1

Common Pitfalls to Avoid

• Using potent or very potent topical corticosteroids on the face can lead to skin atrophy, telangiectasias, and other adverse effects 2
• Non-sedating antihistamines have little to no value in treating eczema 1
• Applying topical treatments more than twice daily does not improve efficacy but may increase side effects 3, 6
• Failure to use emollients regularly alongside topical corticosteroids can reduce treatment effectiveness 1, 2