What is the recommended treatment for eczema on the face?

Treatment of Facial Eczema

Use low-to-moderate potency topical corticosteroids as first-line treatment for facial eczema, applied twice daily maximum to affected areas, with liberal emollient use—avoid potent or very potent corticosteroids on the face due to high risk of skin atrophy in this thin-skinned area. 1, 2

First-Line Treatment Strategy

Topical Corticosteroid Selection for Face

• Apply low-to-moderate potency topical corticosteroids (such as 1% hydrocortisone) to facial eczema twice daily maximum 2
• Use the least potent preparation that achieves adequate control of symptoms 1, 2
• Never use potent or very potent corticosteroids on the face—the thin facial skin has extremely high risk of atrophy and other complications 2
• Implement short "steroid holidays" when the eczema is controlled to minimize side effects including potential pituitary-adrenal suppression 1, 2

Essential Emollient Therapy

• Apply emollients liberally and regularly to facial skin, even when eczema appears controlled, to restore the skin barrier 2
• Apply emollients after bathing to provide a surface lipid film that prevents water loss 1, 2
• Use soap-free cleansers and avoid alcohol-containing products on the face 1, 2

Managing Secondary Infections

Bacterial Infections

• Watch for signs of bacterial superinfection: increased crusting, weeping, or pustules 1, 2
• Prescribe oral flucloxacillin for suspected Staphylococcus aureus infection, the most common pathogen 1, 2
• Continue topical corticosteroids during bacterial infection when appropriate systemic antibiotics are given concurrently—do not delay or withhold corticosteroids 1, 2

Viral Infections (Medical Emergency)

• If you observe grouped vesicles, punched-out erosions, or sudden deterioration with fever, suspect eczema herpeticum and initiate oral acyclovir immediately 1, 2
• This is a medical emergency requiring urgent treatment 1
• In ill, feverish patients, administer acyclovir intravenously 1

Second-Line Treatment for Refractory Facial Eczema

Topical Calcineurin Inhibitors

• For facial eczema refractory to low-potency topical corticosteroids, initiate tacrolimus 0.03% ointment applied twice daily 2
• Tacrolimus is particularly valuable for facial use because it does not cause skin atrophy, unlike corticosteroids 2
• In children aged 2-15 years with moderate-to-severe atopic dermatitis, 0.03% tacrolimus ointment applied twice daily is significantly more efficacious than 1% hydrocortisone acetate 3
• Pimecrolimus 1% cream is an alternative topical calcineurin inhibitor, though it should only be used after other prescription medicines have not worked 4
• Do not use pimecrolimus or tacrolimus in children under 2 years old 4
• The safety of long-term continuous use of topical calcineurin inhibitors is not established; use for short periods with breaks in between 4

Important Safety Considerations for Calcineurin Inhibitors

• A very small number of people using topical calcineurin inhibitors have developed cancer (skin or lymphoma), though a causal link has not been established 4
• Use only on areas with active eczema, not as preventive therapy on normal skin 4
• Stop when signs and symptoms (itching, rash, redness) resolve 4
• The most common side effect is transient skin burning or warmth, typically occurring during the first few days and usually resolving within 3-4 days 4, 3

Managing Pruritus

• Sedating antihistamines may help with nighttime itching through their sedative properties, not through direct anti-pruritic effects 1
• Non-sedating antihistamines have little to no value in atopic eczema and should not be used 1

Critical Pitfalls to Avoid

• Never use potent or very potent corticosteroids on facial skin—the risk of skin atrophy and other complications is unacceptably high in this thin-skinned area 2
• Do not delay topical corticosteroids when infection is present—they remain primary treatment when appropriate systemic antibiotics are given concurrently 1, 2
• Avoid continuous corticosteroid use without breaks—implement treatment holidays when disease is controlled 1, 2
• Do not use topical calcineurin inhibitors continuously for long periods—use short courses with breaks in between 4
• Patients' or parents' fears of steroids often lead to undertreatment—explain the different potencies and emphasize that low-potency preparations are safe for facial use 1

When to Refer or Escalate

• Failure to respond to low-to-moderate potency topical corticosteroids after 4 weeks 1
• Treatment-resistant disease despite optimized topical therapy 2
• Suspected eczema herpeticum (medical emergency requiring immediate treatment) 1, 2
• In children under 7 years with periocular eczema, refer to ophthalmology due to limited ability to communicate symptoms and risk of interference with normal ocular development 2
• Moderate-to-severe facial disease requiring topical corticosteroids for more than 8 weeks 2

Sun Protection During Treatment

• Limit sun exposure during treatment with topical calcineurin inhibitors, even when the medicine is not on the skin 4
• Do not use sun lamps, tanning beds, or ultraviolet light therapy during treatment with topical calcineurin inhibitors 4
• If outdoors after applying topical calcineurin inhibitors, wear loose-fitting clothing that protects treated areas from sun 4