What is the treatment for facial eczema?

Treatment of Facial Eczema

For facial eczema, use topical corticosteroids as first-line treatment, applying the least potent preparation that controls symptoms (typically starting with mild to moderate potency on the face), combined with liberal emollient use and soap-free cleansers. 1

First-Line Treatment Approach

Topical Corticosteroids

• Apply topical corticosteroids twice daily (or once daily for potent preparations) to affected facial areas, using the least potent preparation that achieves control 2, 1
• Start with mild potency corticosteroids on the face due to thinner skin and higher risk of atrophy 1
• Moderate-potency corticosteroids result in treatment success (cleared or marked improvement) in 52% versus 34% with mild potency, though this data is from body sites 3
• Avoid very potent corticosteroids on the face entirely due to high risk of skin atrophy in thin-skinned areas 1
• Implement "steroid holidays" (short breaks) when possible to minimize side effects 2, 1
• Once daily application of potent corticosteroids is as effective as twice daily for flare treatment, though facial eczema typically requires milder potencies 3

Essential Adjunctive Measures

• Use dispersible cream as a soap substitute instead of regular soap, as soaps remove natural lipids and worsen dry skin 2, 4
• Apply emollients liberally after bathing to provide a surface lipid film that prevents water loss 2, 1, 4
• Continue emollients regularly even when eczema appears controlled 1
• Avoid alcohol-containing products on facial skin 1
• Keep nails short to minimize scratching damage 2, 4

Managing Pruritus

• Use sedating antihistamines (not non-sedating) at nighttime only for severe itching through their sedative properties 2, 1, 4
• Non-sedating antihistamines have no value in eczema and should not be used 2, 1, 4
• Antihistamines are short-term adjuvants during severe flares, not maintenance therapy 2, 4

Recognizing and Managing Complications

Secondary Bacterial Infection

• Watch for increased crusting, weeping, or pustules indicating Staphylococcus aureus infection 1
• Start oral flucloxacillin as first-line antibiotic for S. aureus 2, 1, 4
• Use phenoxymethylpenicillin if β-hemolytic streptococci are isolated 2, 4
• Use erythromycin for penicillin allergy or flucloxacillin resistance 2, 4
• Continue topical corticosteroids during bacterial infection when appropriate systemic antibiotics are given concurrently—do not withhold steroids 1

Eczema Herpeticum (Medical Emergency)

• Suspect eczema herpeticum if you observe grouped vesicles, punched-out erosions, or sudden deterioration with fever 2, 1
• This is a medical emergency requiring immediate treatment 1
• Initiate oral acyclovir early in the disease course 2, 1, 4
• In ill, feverish patients, administer acyclovir intravenously 2, 1

Second-Line Options for Facial Eczema

Topical Calcineurin Inhibitors (Pimecrolimus)

• Pimecrolimus 1% cream is particularly useful for facial eczema as it lacks corticosteroid-related side effects like skin atrophy 5
• In real-world use, pimecrolimus achieved treatment success (clear or almost clear) on the face in 81% of patients after 3 months 5
• However, pimecrolimus is less effective than moderate and potent corticosteroids and should be reserved for cases where corticosteroid side effects are a concern 6
• Apply twice daily from first signs until clearance 5
• Do not use in children under 2 years old, and avoid continuous long-term use due to theoretical cancer concerns 7
• Avoid use on malignant or pre-malignant skin conditions 7
• Resolve bacterial or viral infections before starting pimecrolimus 7

Tar Preparations

• Ichthammol (1% in zinc ointment) is less irritant than coal tar and useful for lichenified facial eczema 2, 4
• Coal tar solution (1% in hydrocortisone ointment) is generally preferred to crude coal tar 2, 4
• These do not cause systemic side effects unless used extravagantly 2, 4

Maintenance Strategy to Prevent Flares

Weekend (proactive) therapy with topical corticosteroids applied twice weekly dramatically reduces relapse risk from 58% to 25% 3

• Apply topical corticosteroids to previously affected facial areas twice weekly (e.g., weekends) even when clear 3
• This proactive approach is more effective than waiting to treat flares reactively 3
• Continue for 16-20 weeks or longer as needed 3

Critical Pitfalls to Avoid

• Do not delay topical corticosteroids when infection is present—they remain primary treatment when appropriate antibiotics are given 1
• Patients' or parents' fears of steroids often lead to undertreatment—explain different potencies and that facial eczema requires milder preparations with lower risk 2, 1
• Do not use topical corticosteroids continuously without breaks 1
• Do not apply treatment more than twice daily 2, 4
• Avoid bathing, showering, or swimming immediately after applying treatment as this washes it off 7

When to Refer or Escalate

• Failure to respond to moderate potency topical corticosteroids after 4 weeks 1
• Need for systemic therapy or phototherapy 1
• Suspected eczema herpeticum (immediate referral) 1
• Development of lymphadenopathy without clear infectious etiology 7
• Worsening skin papillomas (warts) that don't respond to conventional therapy 7