Treatment of Facial Eczema
For eczema on the face, start with a mild to moderate potency topical corticosteroid (such as hydrocortisone 1-2.5%) applied once or twice daily, combined with liberal emollient use and soap-free cleansers. 1
First-Line Topical Corticosteroid Selection
The face requires special consideration due to thinner skin and higher risk of atrophy. Use the least potent preparation that achieves control, starting with mild potency corticosteroids on facial areas. 1
- Hydrocortisone 1% cream is FDA-approved for eczema and appropriate for facial use 2
- Apply topical corticosteroids once or twice daily (potent preparations may only need once daily application) 1
- Avoid very potent corticosteroids on the face entirely due to high risk of skin atrophy 1
- Implement "steroid holidays" (short breaks from treatment) when possible to minimize side effects 1
Potency Considerations
If mild corticosteroids fail after 4 weeks, escalation may be necessary:
- Moderate-potency corticosteroids are probably more effective than mild preparations (52% vs 34% treatment success), though this evidence comes primarily from moderate-to-severe eczema 3
- Potent corticosteroids show large increases in effectiveness compared to mild preparations (70% vs 39% treatment success) 3, 4
- However, potent corticosteroids should be used with extreme caution on the face for limited periods only 5
Essential Adjunctive Measures
These are not optional—they form the foundation of eczema management:
- Use a dispersible cream as a soap substitute instead of regular soap, as soaps remove natural lipids and worsen dry skin 1
- Apply emollients liberally after bathing to provide a surface lipid film that prevents water loss 1
- Continue emollients regularly even when eczema appears controlled—this is cornerstone maintenance therapy 6, 1
- Avoid alcohol-containing products on facial skin 1
- Keep nails short to minimize scratching damage 1
Managing Pruritus (Itching)
- Use sedating antihistamines (such as diphenhydramine) at nighttime only for severe itching—their benefit comes from sedative properties, not direct anti-pruritic effects 1
- Non-sedating antihistamines have no value in eczema and should not be used 6, 1
- Antihistamines are short-term adjuvants during severe flares, not maintenance therapy 1
Recognizing and Managing Complications
Secondary Bacterial Infection
Watch for these warning signs:
- Increased crusting, weeping, or pustules indicate Staphylococcus aureus infection 1
- Start oral flucloxacillin as first-line antibiotic for S. aureus 6, 1
- Use phenoxymethylpenicillin if β-hemolytic streptococci are isolated 1
- Critical: Continue topical corticosteroids during bacterial infection when appropriate systemic antibiotics are given concurrently—do not withhold steroids 6, 1
Eczema Herpeticum (Medical Emergency)
- Suspect eczema herpeticum if you observe grouped vesicles, punched-out erosions, or sudden deterioration with fever 6, 1
- Initiate oral acyclovir early in the disease course 6, 1
- In ill, feverish patients, administer acyclovir intravenously 6
Common Pitfalls to Avoid
- Do not delay topical corticosteroids when infection is present—they remain primary treatment when appropriate antibiotics are given 1
- Patient or parent fears of steroids often lead to undertreatment—explain that facial eczema requires milder preparations with lower risk, and that different potencies exist for different body areas 1, 7
- Do not use topical corticosteroids continuously without breaks 1
- Abnormal skin thinning with short-term use (median 3 weeks) is rare (only 26 cases from 2266 participants across trials, or 1%), with most cases occurring with very potent or potent preparations 3, 4
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 requires immediate referral 1