What is the best treatment for contact dermatitis on the face that worsens in winter?

Facial Contact Dermatitis Worsening in Winter: Prevalence and Treatment

Is This Common?

Yes, facial contact dermatitis that worsens in winter is extremely common. 1 Winter months create a perfect storm for contact dermatitis exacerbation: cold air reduces skin barrier function, indoor heating decreases humidity causing excessive dryness, and patients often increase use of moisturizers and emollients that may contain hidden allergens. 2, 1

• The face is one of the most frequently affected sites for contact dermatitis, alongside hands. 3, 4
• Winter-related deterioration occurs because the skin barrier is already compromised by environmental factors, making it more susceptible to both irritants and allergens. 2
• Approximately 75% of contact dermatitis patients have involvement of the face and/or neck region. 5

Best Treatment Approach

The American Academy of Dermatology recommends identifying and avoiding the causative agent, applying topical corticosteroids for inflammation, and using moisturizers to repair the skin barrier as the most effective treatment for contact dermatitis. 1

Step 1: Immediate Barrier Restoration and Anti-Inflammatory Treatment

• Replace all soaps and detergents with emollients immediately, as these are common irritants that perpetuate dermatitis. 1
• Apply mid- to high-potency topical corticosteroids (such as triamcinolone 0.1% or clobetasol 0.05%) twice daily to affected facial areas. 6
• Critical caveat for facial use: Exercise extreme caution with topical corticosteroids on facial skin—prolonged use causes skin thinning, telangiectasia, perioral dermatitis, and red face syndrome due to increased percutaneous absorption. 1
• Use the least potent preparation required to control the eczema, and stop corticosteroids for short periods when possible. 2

Step 2: Aggressive Moisturization Protocol

• Apply moisturizers packaged in tubes (not jars) to prevent contamination. 2, 1
• Use the "soak and smear" technique: soak the face in plain water for 20 minutes, then immediately apply moisturizer to damp skin nightly for up to 2 weeks. 2, 1
• Apply moisturizers after bathing to provide a surface lipid film that retards evaporative water loss. 2
• Reapply moisturizer frequently throughout the day, especially in winter months. 2

Step 3: Identify the Causative Agent

• Obtain a detailed history including initial location of symptoms, spread pattern, relationship to specific products or activities, and recent changes in skincare products (especially winter-specific products). 1
• Pattern and morphology alone are unreliable in distinguishing between irritant, allergic, or endogenous dermatitis on the face. 1
• Refer for patch testing to at least an extended standard series of allergens if dermatitis persists despite treatment or if the causative agent remains unknown. 1, 6
• Common facial allergens include fragrances, preservatives, nickel (from eyeglass frames), and ingredients in cosmetics and moisturizers. 6, 3

Step 4: Complete Allergen/Irritant Avoidance

• Once identified through patch testing, ensure complete avoidance of the allergen. 1
• Substitute all products in contact with the face, using fragrance-free and preservative-free alternatives. 1
• Avoid extremes of temperature; cold winter air should be buffered with scarves or protective clothing. 2

Step 5: Second-Line Therapies for Refractory Cases

If dermatitis persists despite high-potency steroids and allergen avoidance:

• Consider topical tacrolimus 0.1% or pimecrolimus 1% where topical steroids are unsuitable, ineffective, or when chronic facial dermatitis raises concerns about steroid-induced skin damage. 1, 5
• Topical tacrolimus is effective for contact dermatitis and avoids the risk of corticosteroid allergy and skin atrophy. 1
• Do not use pimecrolimus on children under 2 years old. 5
• For severe or recalcitrant cases, consider phototherapy (PUVA), or systemic immunosuppressants like azathioprine or ciclosporin. 1

Critical Pitfalls to Avoid

• Never wash the face with dish detergent or harsh soaps, very hot or very cold water, or disinfectant wipes. 2, 1
• Do not apply products containing topical antibiotics (neomycin, bacitracin) without clear indication, as these are common sensitizers. 2
• Avoid prolonged use of potent topical steroids on the face without breaks, as this causes irreversible skin damage. 1
• Do not over-rely on barrier creams alone, as they have questionable value and may create false security. 1
• Avoid sun exposure and tanning beds during treatment, especially if using topical calcineurin inhibitors. 5

Prognosis

• With early identification and complete avoidance of allergens, resolution is achievable. 1
• However, persistent contact dermatitis has a poor prognosis: only 25% of patients achieve complete healing over 10 years, 50% have intermittent symptoms, and 25% have permanent symptoms despite treatment. 1
• Early aggressive treatment and complete allergen avoidance offer the best chance for resolution. 1