What is the best course of treatment for a patient with a history of eczema (atopic dermatitis), presenting with extensive skin lesions around the mouth and eyes, who is using steroid cream and prescription-strength toothpaste, potentially indicating a bacterial or fungal infection?

Perioral and Periocular Dermatitis with Suspected Steroid-Induced Complications

Stop the topical steroid cream immediately around the mouth and eyes, obtain bacterial swabs, and initiate oral flucloxacillin for presumed secondary bacterial infection while transitioning to emollient-based supportive care only in these sensitive facial areas. 1

Immediate Diagnostic Assessment

Look for these specific clinical signs to differentiate bacterial superinfection from steroid-induced perioral dermatitis:

• Bacterial infection indicators: Crusting, weeping, purulent exudate, or pustules suggest Staphylococcus aureus superinfection requiring systemic antibiotics 1, 2
• Herpes simplex infection: Grouped, punched-out erosions or vesiculation indicate viral superinfection requiring acyclovir 1
• Steroid-induced perioral dermatitis: The extensive perioral distribution combined with ongoing steroid use strongly suggests iatrogenic perioral dermatitis, which occurs specifically from inappropriate facial steroid application 1, 3

Critical consideration: The prescription-strength toothpaste may be contributing to perioral irritation through contact dermatitis, creating a compound problem 1

Immediate Management Steps

Discontinue all topical steroids on the face immediately - continuing steroids on facial skin, especially around the mouth and eyes, causes skin atrophy, telangiectasia, and paradoxically worsens inflammation through tachyphylaxis and rebound phenomena 1, 3, 4

Obtain bacteriological swabs from crusted or weeping areas before initiating antibiotics, though treatment should not be delayed if clinical infection is evident 1

Initiate oral flucloxacillin (or cephalexin if penicillin allergy) for 7-10 days if any signs of bacterial superinfection are present (crusting, weeping, pustules) 1, 5, 2

Facial Skin Care Protocol

Replace all current facial products with the following regimen:

• Cleansing: Use only mild, pH-neutral (pH 5) non-soap cleansers or dispersible creams as soap substitutes - avoid all regular soaps which strip natural lipids 1, 3
• Moisturization: Apply fragrance-free, non-greasy emollients containing petrolatum or mineral oil immediately after gentle face washing to damp skin, creating a protective lipid barrier 3, 5
• Avoid completely: All alcohol-containing preparations, greasy/occlusive creams, topical acne medications, and the prescription toothpaste temporarily until perioral area heals 1, 3

Pat skin dry with clean towels rather than rubbing to minimize trauma 3

Management of Non-Facial Eczema

For eczema on other body areas (not face), continue appropriate treatment:

• Use hydrocortisone 1% or alclometasone dipropionate 0.05% for mild eczema on body, neck, or flexures - these low-potency options are safer for extended use 5
• Apply topical steroids to active eczema areas only, not as prevention 5
• Liberal emollient application to entire body at least once daily, most effective immediately after bathing 1, 5, 2

Monitoring and Follow-Up

Reassess within 48-72 hours to evaluate response to antibiotics and steroid withdrawal 1

Watch for worsening in the first week after steroid cessation - a temporary flare or "rebound phenomenon" may occur but will improve with supportive care alone 4

Refer to dermatology if:

• No improvement after 4 weeks of appropriate treatment 3
• Diagnostic uncertainty between eczema, perioral dermatitis, seborrheic dermatitis, or contact dermatitis 3
• Grouped vesicles suggesting herpes simplex develop (requires immediate acyclovir) 1

Critical Pitfalls to Avoid

Never restart topical steroids on facial skin - the perioral and periocular areas are at highest risk for steroid-induced atrophy and perioral dermatitis, which this patient likely has developed 1, 3

Do not use non-sedating antihistamines - they provide no benefit in eczema or dermatitis beyond placebo 5

Avoid undertreatment of bacterial infection - if clinical signs of infection exist (crusting, weeping), systemic antibiotics are required; topical antibiotics alone are insufficient and promote resistance 1, 2

Do not prescribe oral corticosteroids - systemic steroids can cause severe rebound phenomena in atopic dermatitis and should only be used for life-threatening exacerbations after all other options exhausted 5, 4