What is the best treatment approach for a patient with a history of atopic diseases, presenting with a potential eczema rash under the nose between the nares?

Treatment of Eczema Under the Nose Between the Nares

Apply a mild to moderate potency topical corticosteroid (such as hydrocortisone 1-2.5%) to the affected area twice daily, combined with liberal emollient use, as the face is a thin-skinned area where potent steroids carry higher risk of skin atrophy. 1

First-Line Treatment Strategy

• Start with the least potent topical corticosteroid that controls symptoms - the facial area requires particular caution due to increased risk of adverse effects like skin thinning 2, 1
• Apply topical corticosteroids no more than twice daily to the affected areas under the nose 2, 1
• Avoid very potent or potent corticosteroids on facial skin - these should only be used with extreme caution for limited periods with "steroid holidays" when possible 1
• Continue treatment until signs and symptoms (itching, rash, redness) resolve, then stop 3

Essential Emollient Therapy

• Liberal, regular application of emollients is the cornerstone of maintenance therapy and must continue even when the eczema appears controlled 1, 4
• Apply emollients after bathing to provide a surface lipid film that retards water loss 1
• Use soap-free cleansers and avoid alcohol-containing products on facial skin 1, 5

Alternative First-Line Option for Facial Eczema

• Pimecrolimus (Elidel) cream 1% is FDA-approved specifically for facial eczema and can be used as an alternative to topical corticosteroids, particularly for longer-term management 3, 4
• Apply a thin layer twice daily to affected areas only 3
• Stop when symptoms resolve; if symptoms persist beyond 6 weeks, re-evaluate the diagnosis 3
• Do not use pimecrolimus continuously long-term - use for short periods with breaks in between as needed 3
• Most common side effect is burning or warmth at application site, typically mild and resolving within the first 5 days 3

Managing Pruritus

• Sedating antihistamines help only through their sedative properties for nighttime itching, not through direct anti-pruritic effects 2, 1
• Non-sedating antihistamines have little to no value in atopic eczema and should not be used 2, 4
• Use sedating antihistamines at bedtime only; avoid daytime use 2

Watch for Secondary Infection

• Monitor for signs of bacterial superinfection: increased crusting, weeping, pustules, or failure to respond to appropriate therapy 1, 5
• Flucloxacillin is first-line for Staphylococcus aureus, the most common pathogen 2, 1
• Use erythromycin in penicillin-allergic patients 2
• Continue topical corticosteroids during bacterial infection when appropriate systemic antibiotics are given concurrently 1

Critical Warning: Eczema Herpeticum

• If you observe grouped vesicles, punched-out erosions, or sudden deterioration with fever, suspect eczema herpeticum - this is a medical emergency 1, 6, 5
• Initiate oral acyclovir immediately and early in the disease course 2, 6
• In ill, febrile patients, administer acyclovir intravenously 2, 6

Common Pitfalls to Avoid

• Do not use potent or very potent corticosteroids on facial skin - the perinasal area has thin skin with high risk of atrophy 1, 5
• Do not apply topical corticosteroids continuously without breaks - implement "steroid holidays" to minimize side effects 2, 1
• Patient fears of steroids often lead to undertreatment - explain the different potencies and emphasize that mild-moderate potency steroids are safe for facial use when used appropriately 1
• Do not delay or withhold topical corticosteroids when infection is present if appropriate systemic antibiotics are given 1

When to Refer or Escalate

• Failure to respond to moderate potency topical corticosteroids after 4 weeks 1, 5
• Symptoms persist beyond 6 weeks of appropriate treatment 3
• Need for systemic therapy or phototherapy 1, 5
• Suspected eczema herpeticum (immediate referral required) 1, 6, 5
• Atypical presentation or uncertainty about diagnosis 7