What is the treatment for eczema on the face?

Treatment of Facial Eczema

For facial eczema, start with low to moderate potency topical corticosteroids applied twice daily combined with regular emollients, avoiding very potent steroids on the face due to increased risk of skin atrophy in this thin-skinned area. 1, 2

First-Line Treatment Approach

Topical Corticosteroids

• Use mild to moderate potency topical corticosteroids on facial skin, as very potent and potent preparations should be avoided or used with extreme caution on the face, neck, and other thin-skinned areas where atrophy risk is higher 2
• Apply no more than twice daily to affected areas only 1, 3
• Stop corticosteroids for short periods ("steroid holidays") when symptoms improve to minimize side effects 2
• Continue treatment until signs and symptoms (itching, rash, redness) resolve 4

Essential Skin Care Measures

• Replace all soaps with soap-free cleansers or dispersible cream as a soap substitute, since soaps and detergents strip natural lipids from already-dry eczematous skin 1, 2
• Apply emollients liberally after bathing to create a surface lipid film that prevents water loss 1, 3, 2
• Regular bathing is beneficial for cleansing and hydrating facial skin 1, 3
• Avoid extremes of temperature and irritant materials 1

Second-Line Options When First-Line Fails

Topical Calcineurin Inhibitors

• Pimecrolimus 1% cream (Elidel) is FDA-approved for facial eczema in patients age 2 years and older when other treatments have failed or are not advisable 4
• Apply twice daily only to affected areas, using the smallest amount needed 4
• Most common side effect is burning or warmth at application site, typically mild and resolving within the first week 4
• Critical safety warning: Use only for short periods with breaks in between; do not use continuously long-term due to uncertain cancer risk 4
• Tacrolimus 0.1% is more effective than pimecrolimus but also causes more local burning 5, 6

Alternative Approaches

• JAK inhibitors (ruxolitinib 1.5%) rank among the most effective treatments in recent network meta-analysis, comparable to potent steroids and tacrolimus 6
• Coal tar preparations (1% in hydrocortisone ointment) can be used but are generally less preferred for facial application 1

Managing Complications

Secondary Bacterial Infection

• Watch for increased crusting, weeping, or pustules indicating bacterial superinfection 2
• Prescribe flucloxacillin orally for Staphylococcus aureus, the most common pathogen 1, 2
• Continue topical corticosteroids during infection when appropriate systemic antibiotics are given concurrently 2

Eczema Herpeticum (Medical Emergency)

• Suspect if you see grouped vesicles, punched-out erosions, or sudden deterioration with fever 1, 2
• Start oral acyclovir immediately; use IV acyclovir if patient is ill or febrile 1, 2

Adjunctive Measures

For Severe Pruritus

• Sedating antihistamines at bedtime may help through sedative (not antipruritic) effects 1, 2
• Non-sedating antihistamines have no value and should not be used 1, 2
• Keep nails short to minimize scratching damage 1, 3

Sun Protection

• Limit sun exposure and avoid tanning beds/UV therapy while using topical treatments 4
• Wear protective clothing if outdoors after applying medication 4

Critical Pitfalls to Avoid

• Do not use very potent or potent corticosteroids on facial skin except for very limited periods under specialist guidance 2
• Do not delay topical corticosteroids when infection is present—they remain primary treatment when appropriate antibiotics are given 2
• Do not use pimecrolimus in children under 2 years of age 4
• Address parental steroid phobia directly, as this commonly leads to undertreatment 1, 2

When to Refer

• Failure to respond to moderate potency topical corticosteroids after 4 weeks 2
• Suspected eczema herpeticum (immediate referral) 2
• Need for systemic therapy or phototherapy 2

Special Consideration for Recalcitrant Cases

For severe, treatment-resistant facial eczema in children, hydrocolloid dressing face-masks (with or without topical corticosteroids underneath) achieved symptomatic control within hours and marked improvement by 7 days in case reports 7