What topical treatments are recommended for a patient with eczema on the face?

Treatment of Facial Eczema

Apply a low-potency topical corticosteroid (such as hydrocortisone 1%) twice daily to affected facial areas as first-line treatment, combined with liberal emollient use after bathing. 1, 2, 3

First-Line Topical Corticosteroid Strategy for the Face

The face requires special consideration due to increased risk of skin atrophy with potent steroids. 3

• Use only low-potency topical corticosteroids on the face - hydrocortisone 1% is adequate and does not cause systemic side effects unless used extravagantly 1, 3
• Apply no more than twice daily to affected areas 1, 2
• Avoid high-potency corticosteroids on the face, neck, and skin folds due to increased atrophy risk 3
• Stop treatment when symptoms (itching, rash, redness) resolve, or implement short "steroid holidays" when possible 2, 3

Critical caveat: Address steroid phobia directly - 72.5% of patients worry about topical corticosteroids, which leads to undertreatment. 3 Explain that low-potency preparations like hydrocortisone 1% are safe for facial use when used appropriately. 1

Essential Emollient Therapy

Emollients are the cornerstone of maintenance and must be used liberally, even when eczema appears controlled. 2

• Apply emollients after bathing to provide a surface lipid film that retards water loss 1, 2
• Use at least once daily to the whole body, though 3-8 times daily may be needed 1
• Urea-glycerol containing creams are superior - they strengthen the skin barrier and protect against irritation better than simple paraffin-based emollients 4
• Glycerol-containing moisturizers perform better than plain paraffin creams 4
• Apply moisturizers after topical corticosteroids, not before 2

Alternative for Sensitive Facial Areas

For recurrent facial eczema or steroid-sensitive areas, topical calcineurin inhibitors (pimecrolimus 1% cream or tacrolimus ointment) are safer alternatives to avoid atrophy. 1, 5

• Pimecrolimus 1% cream is FDA-approved for facial eczema in patients age 2 years and older 6
• Apply twice daily to affected areas only 6
• Do not use in children under 2 years old 6
• Use for short periods with breaks in between, not continuously long-term 6
• Stop when symptoms resolve 6
• Most common side effect is burning or warmth sensation during first 5 days, which typically resolves 6

Important safety warnings for calcineurin inhibitors: 6

• Avoid sun exposure and tanning beds during treatment 6
• Do not use on clinically infected eczema until infection is treated 6
• Discontinue if lymphadenopathy develops without clear infectious cause 6
• Not for continuous long-term use due to theoretical cancer concerns 6

Managing Secondary Infection

Watch for signs of bacterial infection: increased crusting, weeping, or pustules. 2

• Flucloxacillin is first-line for Staphylococcus aureus, the most common pathogen 1, 2
• Continue topical corticosteroids during bacterial infection when appropriate systemic antibiotics are given concurrently 2
• Suspect eczema herpeticum if you see grouped vesicles, punched-out erosions, or sudden deterioration with fever - this is a medical emergency requiring immediate oral or IV acyclovir 1, 2

Managing Pruritus

• Sedating antihistamines (like clemastine) may help nighttime itching through sedative properties, not anti-pruritic effects 1, 2
• Non-sedating antihistamines have no value in atopic eczema and should not be used 1, 2, 7
• Urea- or polidocanol-containing lotions can soothe pruritus 1

Adjunctive Skin Care Measures

• Use soap-free cleansers - soaps remove natural lipids from already dry skin 3
• Keep nails short to minimize damage from scratching 1
• Avoid woolen clothing next to skin; cotton is preferred 1
• Regular bathing for cleansing and hydration is beneficial 1, 2

What NOT to Do

• Do not use oral antihistamines expecting direct anti-eczema effects - evidence shows no benefit beyond sedation 7
• Do not use topical or oral antibiotics prophylactically for uninfected eczema - no evidence supports this 7
• Do not apply treatments more than twice daily - no additional benefit 1
• Do not use very potent or potent corticosteroids on the face - high atrophy risk 1, 3

When to Escalate or Refer

• Failure to respond to low-potency topical corticosteroids after 4 weeks 2, 3
• Need for systemic therapy 2, 3
• Suspected eczema herpeticum (medical emergency) 2
• Diagnostic uncertainty 3