Management of Non-Itchy, Flaky, Red, Swollen Rash on Elderly Man's Cheek
This presentation is highly concerning for a secondary bacterial infection (likely Staphylococcus aureus) complicating underlying dermatitis, and requires immediate initiation of oral flucloxacillin while simultaneously treating the inflammatory component with low-potency topical corticosteroids.
Immediate Clinical Assessment
The absence of pruritus in an elderly patient with facial dermatitis is atypical and should raise suspicion for:
- Secondary bacterial infection: Look specifically for crusting, weeping, honey-colored discharge, or increased warmth 1
- Eczema herpeticum: Examine for grouped vesicles, punched-out erosions, or sudden deterioration with systemic symptoms—this is a medical emergency 1, 2
- Contact dermatitis: Inquire about new topical products, medications, or environmental exposures 1
Obtain bacterial swabs if infection is suspected based on clinical appearance 1. If grouped vesicular lesions are present, send viral culture or PCR for herpes simplex virus 1, 2.
First-Line Treatment Protocol
For Suspected Bacterial Superinfection (Most Likely Scenario)
Initiate oral flucloxacillin 500 mg four times daily for 14 days, as this is the most appropriate antibiotic for S. aureus, the commonest pathogen in infected dermatitis 1, 3, 4. Alternative options include:
- Erythromycin if penicillin allergy 1
- Cephalexin (cephadroxil 500 mg twice daily) if intolerance to flucloxacillin 1
Simultaneously apply low-potency topical corticosteroid (hydrocortisone 2.5% or alclometasone 0.05%) twice daily to the affected cheek 1, 3. Do not withhold topical corticosteroids when infection is present—they remain primary treatment when appropriate systemic antibiotics are given concurrently 3, 2.
Essential Adjunctive Measures
- Apply emollients liberally at least twice daily to the entire face, using fragrance-free, alcohol-free preparations 1, 3, 4
- Avoid soap and use soap-free cleansers to prevent further lipid removal from already compromised skin 1, 3
- Avoid hot water when washing the face 1
If Eczema Herpeticum is Suspected
Immediately initiate oral acyclovir 400 mg five times daily (or 800 mg three times daily) for 7-10 days 1, 2. Early medication initiation directly correlates with decreased morbidity and length of illness 2. Before acyclovir availability, mortality rates reached 10-50% in untreated cases 2.
If the patient appears systemically unwell with fever, administer intravenous acyclovir and consider hospital admission 1, 2.
Continue topical corticosteroids during antiviral treatment 2.
Monitoring and Reassessment
Reassess after 7-10 days to evaluate treatment response 3, 4. If no improvement occurs, consider:
- Poor treatment adherence 4
- Resistant organisms—obtain bacterial culture and sensitivities 1
- Alternative diagnosis (contact dermatitis, psoriasis, seborrheic dermatitis) 1
- Need for dermatology referral 1
Critical Pitfalls to Avoid
- Never delay antibiotics when bacterial infection is clinically suspected based on crusting, weeping, or increased erythema 1
- Never use potent or very potent corticosteroids on facial skin due to dramatically increased risk of atrophy, telangiectasia, and perioral dermatitis 1, 3
- Never mistake eczema herpeticum for simple bacterial infection—the presence of grouped vesicles and punched-out erosions distinguishes this life-threatening condition 1, 2
- Never discontinue topical corticosteroids when treating concurrent infection with appropriate systemic antimicrobials 3, 2