What is the treatment for an allergic reaction on the face?

Treatment of Facial Allergic Reactions

For an allergic reaction on the face, immediately apply a mild-to-moderate potency topical corticosteroid such as hydrocortisone 1-2.5% cream 1-2 times daily, combined with liberal emollient use, while monitoring closely for signs of anaphylaxis that would require intramuscular epinephrine. 1, 2, 3

Immediate Assessment: Rule Out Anaphylaxis First

Before treating a localized facial reaction, quickly assess for systemic involvement:

• Look for difficulty breathing, mucosal swelling (lips, tongue, throat), urticaria spreading beyond the face, abdominal cramping, or hypotension 4
• If any systemic symptoms are present, this is anaphylaxis—administer intramuscular epinephrine 0.3-0.5 mg immediately into the lateral thigh and call emergency services 5, 4
• Only after epinephrine should you consider adjunctive medications like antihistamines or corticosteroids 4

First-Line Treatment for Localized Facial Reactions

Topical Corticosteroids

Use mild-to-moderate potency preparations on facial skin, as this is a thin-skinned area at higher risk for atrophy:

• Apply hydrocortisone 1-2.5% cream or prednicarbate 0.02% cream to affected areas 1-2 times daily 1, 2, 3
• The FDA label for hydrocortisone specifies application not more than 3-4 times daily for adults and children over 2 years 3
• Avoid very potent corticosteroids on the face—they carry unacceptable risk of skin atrophy, telangiectasia, and perioral dermatitis 1, 2
• Apply for short periods only with "steroid holidays" when symptoms improve to minimize adverse effects 2

Essential Adjunctive Measures

• Apply emollients liberally and regularly, even after the reaction improves—this is the cornerstone of skin barrier restoration 1, 2
• Use soap-free cleansers and avoid alcohol-containing products on facial skin 6, 1
• Avoid hot water and excessive washing, which dehydrate the skin further 6

Managing Itching (Pruritus)

• Sedating antihistamines like diphenhydramine or clemastine may help with nighttime itching through sedation, not direct anti-pruritic effects 1, 2
• Non-sedating antihistamines (cetirizine, loratadine, fexofenadine) have little value for eczematous reactions and should not be relied upon 2
• However, for acute urticarial (hives) reactions, oral fexofenadine 180 mg works as rapidly as diphenhydramine with fewer adverse effects 7, 8

Watch for Secondary Bacterial Infection

The face is particularly vulnerable to secondary infection:

• Look for increased crusting, weeping, pustules, or honey-colored discharge—these indicate Staphylococcus aureus superinfection 6, 1, 2
• If infection is present, start oral flucloxacillin while continuing topical corticosteroids 1, 2
• Do NOT withhold topical steroids when infection is present—they remain essential when appropriate antibiotics are given concurrently 2

Critical Red Flags: Eczema Herpeticum

• If you observe grouped vesicles, punched-out erosions, or sudden deterioration with fever, suspect eczema herpeticum—this is a medical emergency 1, 2
• Initiate oral acyclovir immediately; if the patient appears ill or febrile, administer intravenous acyclovir 1, 2

When to Escalate or Refer

• Failure to respond to moderate potency topical corticosteroids after 4 weeks 1, 2
• Severe symptoms requiring systemic therapy 1, 2
• Any signs of anaphylaxis or eczema herpeticum 1, 2, 4
• Persistent grade I allergic reactions despite intramuscular epinephrine may require continuous low-dose intravenous epinephrine under cardiac monitoring 9

Common Pitfalls to Avoid

• Do not use potent or very potent corticosteroids on facial skin—the risk of atrophy far outweighs benefits 1, 2
• Do not apply topical steroids continuously without breaks—implement treatment holidays when symptoms improve 2
• Do not delay treatment due to "steroid phobia"—undertreatment leads to worse outcomes and prolonged suffering 2
• Do not assume all facial reactions are benign—always assess for systemic involvement requiring epinephrine 5, 4