Treatment of Facial Eczema
For eczema on the face, use a low-potency topical corticosteroid (such as 1% hydrocortisone) applied no more than twice daily, combined with liberal emollient use after cleansing, while avoiding very potent or potent corticosteroids on facial skin due to high risk of atrophy. 1, 2
First-Line Treatment Approach
Topical Corticosteroids
- Apply the least potent corticosteroid preparation that controls symptoms to facial areas 1, 2
- Hydrocortisone 1% is appropriate for facial eczema and can be applied 3-4 times daily for itching, inflammation, and rashes 3
- Avoid very potent and potent corticosteroids on the face, neck, and other thin-skinned areas where risk of skin atrophy is significantly higher 2
- Apply no more than twice daily (or up to 3-4 times for hydrocortisone specifically) 1, 3
- Implement "steroid holidays" - short breaks from corticosteroid use when possible to minimize side effects 2
Essential Emollient Therapy
- Liberal and regular emollient use is the cornerstone of maintenance therapy and must be continued even when eczema appears controlled 2, 4
- Apply emollients after bathing/cleansing to provide a surface lipid film that prevents water loss from the skin 1, 2
- Emollients reduce flares (risk ratio 0.40) and prolong time to flare (median 180 vs 30 days without moisturizer) 4, 5
- Emollient use reduces the amount of topical corticosteroids needed by approximately 9.3g over 6-8 weeks 4, 5
Skin Cleansing
- Use a dispersible cream as a soap substitute instead of regular soap, as soaps and detergents remove natural protective lipids from already-dry eczematous skin 1, 6
- Use soap-free cleansers and avoid alcohol-containing products 2
- Regular bathing for cleansing and hydrating is beneficial 1, 2
Choosing the Right Emollient
Evidence-Based Emollient Selection
- Urea-containing creams with glycerol demonstrate superior barrier strengthening compared to simple paraffin-based emollients 7
- Urea-glycerol creams significantly reduce skin sensitivity to irritants (reduction of 9.0 g/m²/h in transepidermal water loss) and improve natural moisturizing factor levels 7
- Glycerol-containing moisturizers show moderate effectiveness with improved SCORAD scores, though the minimal important difference may not be met 5
- Simple paraffin-based emollients (the most widely prescribed type) show no effect on skin barrier function and may actually reduce natural moisturizing factors 7
- Most patients prefer a non-fragrant, non-herbal white cream that requires only 2-3 times daily application 8
Managing Complications
Secondary Bacterial Infection
- Watch for increased crusting, weeping, or pustules indicating bacterial infection 2
- Continue topical corticosteroids during bacterial infection when appropriate systemic antibiotics are given concurrently 2
- Flucloxacillin is first-line for Staphylococcus aureus (the most common pathogen) 1, 2, 6
- Use erythromycin for penicillin allergy 1, 6
Eczema Herpeticum (Medical Emergency)
- Suspect eczema herpeticum if you observe grouped vesicles, punched-out erosions, or sudden deterioration with fever 2
- Initiate oral acyclovir early in the disease course 1, 2, 6
- Administer intravenous acyclovir in ill, feverish patients 1, 2, 6
Managing Pruritus
- Sedating antihistamines help with nighttime itching through sedative properties, not direct anti-pruritic effects 2, 6
- Use sedating antihistamines at night only; avoid daytime use 1, 6
- Non-sedating antihistamines have little to no value in atopic eczema and should not be used 1, 2, 6
Critical Pitfalls to Avoid
- Do not withhold topical corticosteroids when infection is present - they remain primary treatment when appropriate systemic antibiotics are given 2
- Never use very potent or potent corticosteroids on facial skin due to high atrophy risk 2
- Patients' or parents' fears of steroids often lead to undertreatment - clearly explain different potencies and the benefit-risk profile 1, 2
- Do not use topical corticosteroids continuously without breaks 2