What is the treatment for eczema on the face?

Treatment of Facial Eczema

For facial eczema, start with topical corticosteroids as the mainstay of treatment, using the least potent preparation that controls symptoms, combined with regular emollients and avoidance of irritants. 1, 2

First-Line Treatment Approach

Topical Corticosteroids

• Apply a low to medium potency topical corticosteroid twice daily to affected facial areas until symptoms improve, then taper frequency 1, 3, 4
• Use the least potent preparation required to maintain control, stopping for short periods when possible to minimize side effects 1, 2
• For facial eczema specifically, avoid very potent corticosteroids due to increased risk of skin thinning and other adverse effects on thinner facial skin 1
• Recent network meta-analysis confirms potent corticosteroids rank among the most effective treatments, though moderate potency is typically sufficient for facial application 3, 4

Essential Skin Care Measures

• Replace all soaps and detergents with dispersible cream as a soap substitute, as these remove natural lipids that are already deficient in eczema 1, 2
• Apply emollients immediately after bathing while skin is still slightly damp to provide a surface lipid film that retards water loss 1, 2
• Avoid extremes of temperature and keep nails short to minimize trauma from scratching 1, 2

Second-Line Options for Steroid-Sparing or Refractory Cases

Topical Calcineurin Inhibitors

• Consider tacrolimus 0.1% or pimecrolimus 1% cream for facial eczema when prolonged corticosteroid use is concerning 5, 6, 4
• These agents are particularly useful for facial application where long-term steroid use risks skin atrophy 5
• Apply twice daily to affected areas; tacrolimus 0.1% ranks among the most effective treatments in network meta-analysis 3, 4
• Important caveat: Expect application-site burning or warmth, especially during the first 5 days, which typically resolves within one week 6
• Do not use in children under 2 years of age, and use only for short periods with breaks in between 6
• Avoid sun exposure and do not use with UV light therapy while using these medications 6

JAK Inhibitors (Newer Option)

• Ruxolitinib 1.5% cream ranks among the most effective treatments in recent meta-analyses for both patient-reported symptoms and clinician-assessed signs 3, 4
• Consider for moderate to severe facial eczema not responding to first-line treatments 3, 4

Management of Complications

Secondary Bacterial Infection

• Suspect infection when crusting, weeping, or worsening occurs despite appropriate treatment 1
• Treat with flucloxacillin for Staphylococcus aureus or erythromycin if penicillin-allergic 2, 5
• Bacteriological swabs are not routine but obtain if treatment fails 1

Herpes Simplex Infection (Eczema Herpeticum)

• Look for grouped, punched-out erosions or vesiculation on the face 1
• Start oral acyclovir immediately if suspected 2, 5

Treatment Algorithm by Severity

Mild facial eczema:

• Low potency topical corticosteroid twice daily + emollients + soap avoidance 1, 2

Moderate facial eczema:

• Medium potency topical corticosteroid twice daily initially, then taper 1, 3
• If prolonged use needed, switch to tacrolimus 0.1% or pimecrolimus 1% 5, 6

Severe or refractory facial eczema:

• Consider tacrolimus 0.1% or ruxolitinib 1.5% as alternatives to potent corticosteroids 3, 4
• For children with recalcitrant facial eczema, hydrocolloid dressing face-masks with or without corticosteroids underneath can provide rapid symptom control within hours 7

Critical Caveats

• Do not use potent or very potent corticosteroids on the face for extended periods due to risk of skin atrophy, though short-term use (median 3 weeks) shows no increased skin thinning 1, 4
• Stop treatment when symptoms resolve (itching, rash, redness) or as directed, and call your physician if symptoms worsen, infection develops, or no improvement occurs after 6 weeks 6
• Sedating antihistamines have value only for their sedative properties during severe pruritic episodes at night, not for daytime use 1, 2
• Patient education about proper application technique and quantity is essential for treatment success 1