What topical steroid is recommended for facial eczema?

Topical Corticosteroid for Facial Eczema

For facial eczema, use hydrocortisone 1% (low-potency topical corticosteroid) as first-line treatment, applying once or twice daily for short courses to control flares. 1, 2

Why Hydrocortisone 1% for the Face

Hydrocortisone 1% is specifically recommended for facial application because it minimizes the risk of skin atrophy, which is a particular concern on the face where skin is thinner and more susceptible to steroid-related adverse effects. 2 The fundamental principle in treating facial eczema is to use the least potent preparation required to keep the eczema under control, with intermittent breaks when possible. 3, 2

• Hydrocortisone 1% is classified as Class 6-7 (low potency), making it the safest option for sensitive facial skin 2
• Very potent and potent category steroids should be used with caution for limited periods only and are generally inappropriate for routine facial eczema management 3, 2

Application Protocol

Apply topical corticosteroids once or twice daily—once daily application is probably sufficient for most cases. 4 Evidence from 15 trials (1821 participants) shows that applying potent topical corticosteroids only once daily probably does not decrease treatment success compared to twice daily application. 3

• Apply after bathing when skin is slightly damp for better absorption 1
• Treatment should not be applied more than twice daily 3
• Use for short courses to control flares, then stop for short periods when possible 3, 1

Essential Adjunctive Therapy

Combine hydrocortisone with regular emollient use—this is fundamental, not optional. 2 Topical steroids alone are insufficient for managing eczema. 2

• Use dispersible cream as a soap substitute rather than regular soaps, which remove natural lipids and worsen dry skin 3, 1, 2
• Apply emollients at least 30 minutes before or after topical corticosteroids 1
• Emollients are most effective when applied after bathing 3

Periocular (Around the Eyes) Considerations

For moderate-to-severe eczema specifically around the eyes, preservative-free dexamethasone 0.1% may be used for short-term treatment (maximum 8 weeks). 1 However, this requires careful monitoring and consideration of early introduction of steroid-sparing agents like tacrolimus ointment to facilitate tapering. 1

Critical Safety Points

The main risk with more potent steroids is suppression of the pituitary-adrenal axis, particularly in children, which is why low potency options are preferred for facial use. 3, 2 Short-term use (median 3 weeks) of topical corticosteroids shows no evidence for increased skin thinning, though longer-term use (6-60 months) does show increased risk. 5

Common Pitfalls to Avoid

Undertreatment due to steroid phobia is extremely common. 3, 2 Many patients and parents have unfounded fears about topical steroids that lead to inadequate treatment; education about appropriate use and safety is essential. 3, 2

• Using inappropriately potent steroids on the face increases risk of skin atrophy, telangiectasia, and other local adverse effects 2
• Failure to use adequate emollients—regular emollient use is fundamental to managing the dry skin component of eczema 2

When to Escalate or Refer

• If no improvement after 4 weeks of appropriate treatment, consider referral to a dermatologist 1
• Evaluate for secondary bacterial infection if treatment is not effective (suggested by crusting or weeping) 3, 1
• Consider patch testing to identify potential contact allergens that may be exacerbating the condition 1

Additional Supportive Measures

• Keep nails short to minimize damage from scratching 3, 1
• Avoid extremes of temperature 3
• Avoid irritant clothing such as wool next to the skin; cotton clothing is preferred 3
• For severe pruritus, sedating antihistamines may be useful as a short-term adjuvant during relapses 3, 1