What is the best treatment approach for a patient presenting with eczema (atopic dermatitis) on the face?

Treatment of Facial Eczema (Atopic Dermatitis)

For facial eczema, use low-to-moderate potency topical corticosteroids as first-line therapy, applied once daily (not twice daily) to affected areas, combined with aggressive emollient therapy. 1, 2, 3

Topical Corticosteroid Selection for the Face

The face requires special consideration due to thin skin and higher risk of steroid-induced atrophy. Use the least potent preparation that controls the eczema—typically low-to-moderate potency steroids on facial skin. 1 Very potent and potent corticosteroids should be avoided on the face except for very limited periods during severe flares. 1

• Apply topical corticosteroids once daily only—twice daily application provides no additional benefit and increases side effect risk. 3
• Implement "steroid holidays" (short breaks) when the eczema is controlled to minimize adverse effects like skin thinning. 1
• Parents often undertreate facial eczema due to steroid phobia; clear education about appropriate potency selection and the safety profile when used correctly is essential. 1

Topical Calcineurin Inhibitors as Steroid-Sparing Agents

Topical calcineurin inhibitors (pimecrolimus or tacrolimus) are particularly useful for sensitive facial areas where long-term corticosteroid use poses atrophy risk. 2 These can be used in conjunction with topical corticosteroids as first-line treatment for facial involvement. 2

Essential Emollient Therapy

Liberal emollient use is the cornerstone of maintenance therapy and must continue even when facial eczema appears controlled. 1

• Apply emollients immediately after bathing (within 3 minutes of patting skin dry) to trap moisture when skin is most hydrated. 4
• Use fragrance-free ointments or thick creams rather than lotions for maximum occlusion. 4
• Apply at least twice daily, with more frequent application (3-4 times daily) for moderate-to-severe cases. 4
• Use soap-free cleansers exclusively and avoid hot water, as these strip natural skin lipids. 1, 5

Managing Pruritus

Sedating antihistamines (diphenhydramine or hydroxyzine) should only be used at nighttime for severe itching, as their benefit comes from sedation rather than direct anti-pruritic effects. 4, 1, 5

Non-sedating antihistamines have no value in atopic eczema and should not be prescribed. 4, 1, 3 This is a common pitfall—oral antihistamines do not reduce eczema-related pruritus through antihistamine mechanisms. 2, 3

Identifying and Treating Secondary Infection

Watch for signs of secondary bacterial infection: increased crusting, weeping, or pustules indicating Staphylococcus aureus colonization. 1, 5

• Add oral flucloxacillin as first-line antibiotic while continuing topical corticosteroids—do not delay or withhold steroids when infection is present. 1, 5
• Topical or oral antistaphylococcal treatments for infected eczema lack strong evidence and should generally be avoided in favor of systemic antibiotics when truly infected. 3

If you observe grouped vesicles, punched-out erosions, or sudden deterioration with fever, suspect eczema herpeticum—this is a medical emergency requiring immediate oral or IV acyclovir. 1

Proactive Maintenance Strategy

After achieving clearance, apply topical corticosteroids twice weekly (weekend therapy) to previously affected facial sites to prevent relapse. 4, 5 This "get control then keep control" regimen reduces flare frequency. 3

Novel Approach for Recalcitrant Facial Eczema

For children with recalcitrant facial eczema unresponsive to standard therapy, consider face-masks made from hydrocolloid dressings (such as DuoDerm extra thin), with or without a single application of topical corticosteroid underneath. 6 This approach provides symptomatic control within hours and marked improvement by 7 days, with remissions lasting over 3 months. 6

When to Refer

• Failure to respond to moderate potency topical corticosteroids after 4 weeks. 1
• Need for systemic therapy or phototherapy. 1
• Suspected eczema herpeticum (medical emergency). 1

Critical Pitfalls to Avoid

• Do not use twice-daily corticosteroid application—once daily is equally effective with lower side effect burden. 3
• Do not prescribe non-sedating antihistamines—they provide no benefit for eczema pruritus. 4, 1, 3
• Do not withhold topical corticosteroids when infection is present—they remain primary treatment when appropriate systemic antibiotics are given concurrently. 1, 5
• Do not use systemic corticosteroids for maintenance—they have a limited role only for tiding patients through acute severe flares after exhausting all other options. 1, 7