What is the recommended treatment for eczema (atopic dermatitis) on the face?

Treatment of Facial Eczema

For facial eczema, apply low-potency topical corticosteroids (such as 1% hydrocortisone) twice daily as first-line treatment, using the least potent preparation that controls symptoms, with special caution given the thin facial skin and high risk of atrophy. 1, 2, 3

First-Line Treatment Approach

Topical Corticosteroids

• Start with low-to-moderate potency topical corticosteroids applied twice daily maximum to affected facial areas. 1, 2, 3
• Use 1% hydrocortisone or equivalent mild-potency preparations for facial eczema, as this provides adequate control without causing systemic side effects when used appropriately. 1
• Never use very potent or potent corticosteroids on the face due to extremely high risk of skin atrophy, telangiectasia, and perioral dermatitis in this thin-skinned area. 3
• Implement "steroid holidays"—stop corticosteroids for short periods once symptoms improve to minimize pituitary-adrenal suppression and local side effects. 1, 2
• In children, use topical corticosteroids with particular caution due to increased risk of systemic absorption and potential growth interference. 3

Essential Emollient Therapy

• Apply emollients liberally and regularly to the entire face, even when eczema appears controlled, as this is the cornerstone of maintenance therapy. 1, 2
• Apply emollients immediately after bathing to provide a surface lipid film that prevents evaporative water loss from the epidermis. 1, 2
• Use dispersible cream as a soap substitute instead of regular soap, which strips natural lipids and worsens the already compromised skin barrier. 1
• Avoid alcohol-containing products on facial skin. 2

Avoidance of Aggravating Factors

• Avoid extremes of temperature, which can trigger facial flares. 1
• Identify and eliminate exposure to irritants through careful history-taking. 1
• Keep nails short to minimize damage from scratching. 1

Managing Secondary Infections

Bacterial Infections

• Watch for signs of bacterial superinfection: increased crusting, weeping, or pustules on facial skin. 1, 2
• Prescribe oral flucloxacillin as first-line antibiotic for Staphylococcus aureus, the most common pathogen in infected eczema. 1, 2
• Use erythromycin if penicillin allergy exists. 1
• Continue topical corticosteroids during bacterial infection when appropriate systemic antibiotics are given concurrently—infection is not a contraindication to topical steroid use. 2, 4

Viral Infections (Medical Emergency)

• If you observe grouped vesicles, punched-out erosions, or sudden deterioration with fever, suspect eczema herpeticum—this is a medical emergency. 1, 2
• Initiate oral acyclovir immediately and early in the disease course. 1, 2
• In ill, feverish patients with suspected eczema herpeticum, administer acyclovir intravenously. 1, 2

Second-Line Treatment for Refractory Facial Eczema

Topical Calcineurin Inhibitors

• For facial eczema refractory to low-potency topical corticosteroids after 4 weeks, initiate tacrolimus 0.03% (for children 2-15 years) or tacrolimus 0.1% (for adults) applied twice daily. 3, 5
• Pimecrolimus 1% cream is an alternative topical calcineurin inhibitor approved for mild-to-moderate facial atopic dermatitis in patients 2 years and older. 5
• Topical calcineurin inhibitors are particularly valuable for facial eczema because they do not cause skin atrophy, making them safer for long-term use on thin facial skin. 3, 6
• Warn patients that application-site burning or warmth is the most common side effect, usually mild-to-moderate, occurring during the first 5 days of treatment and typically resolving within a few days. 5
• Do not use topical calcineurin inhibitors continuously for prolonged periods—use them for short periods with breaks in between, stopping when signs and symptoms resolve. 5
• Tacrolimus and pimecrolimus should not be used in patients with a history of ocular herpes simplex virus or varicella zoster virus. 3

Proactive Therapy for Long-Term Control

• Once facial eczema is controlled with topical corticosteroids or calcineurin inhibitors, consider proactive therapy: intermittent low-dose application of anti-inflammatory agents (twice weekly) to previously affected facial areas, combined with ongoing daily emollient use. 7, 8
• This approach prevents flares by treating subclinical inflammation in normal-appearing skin, which is immunobiologically abnormal in atopic dermatitis patients. 7, 8

Managing Pruritus

• Sedating antihistamines (such as hydroxyzine or diphenhydramine) may help with nighttime facial itching through their sedative properties, not through direct anti-pruritic effects—reserve for nighttime use during severe flares only. 1, 2
• Non-sedating antihistamines have no value in atopic eczema and should not be used. 1, 2
• Large doses of antihistamines may be required in children, but use should be limited to nighttime to avoid daytime sedation. 1

Alternative Treatments for Specific Situations

Tar Preparations

• Ichthammol 1% in zinc ointment can be applied to lichenified facial eczema, as it is less irritant than coal tar. 1
• Coal tar solution 1% with hydrocortisone is adequate for facial use and does not cause systemic side effects unless used extravagantly. 1

Occlusive Dressings for Recalcitrant Cases

• For recalcitrant facial eczema in children, consider face-masks made from hydrocolloid dressings (such as DuoDerm extra thin), with or without a single application of potent topical corticosteroid underneath. 9
• These face-masks provide symptomatic control within hours and marked improvement by 7 days, lasting 1-4 days per application. 9

Critical Pitfalls to Avoid

• Never delay or withhold topical corticosteroids when facial infection is present—they remain the primary treatment when appropriate systemic antibiotics are given concurrently. 2, 4
• Do not undertreat facial eczema due to steroid phobia—explain to patients that appropriate short-term use of low-potency steroids is safer than chronic undertreated inflammation. 1, 2
• Avoid potent or very potent corticosteroids on facial skin due to extremely high risk of atrophy, telangiectasia, and perioral dermatitis. 1, 3
• Do not use topical corticosteroids continuously without breaks—implement regular "steroid holidays" when disease is controlled. 1, 2
• Do not apply emollients directly to acutely inflamed facial skin, as this is poorly tolerated—treat the flare first with topical corticosteroids. 8
• Avoid sun exposure and tanning beds during treatment with topical calcineurin inhibitors, and use sun protection even when the medicine is not on the skin. 5

When to Refer to Dermatology

• Failure to respond to low-potency topical corticosteroids after 4 weeks of appropriate use. 2, 3
• Symptoms worsening despite appropriate treatment. 2, 5
• Need for systemic therapy or phototherapy. 2
• Suspected eczema herpeticum (refer emergently). 2, 3
• Diagnostic uncertainty distinguishing facial eczema from seborrheic dermatitis, contact dermatitis, or rosacea. 4
• Periocular eczema in children under 7 years old due to limited ability to communicate symptoms and risk of interference with normal ocular development. 3
• Moderate-to-severe facial disease requiring topical corticosteroids for more than 8 weeks. 3