What is the first‑line management for facial eczema (atopic dermatitis)?

First-Line Management of Facial Eczema

Apply liberal emollients daily—immediately after bathing—and use low-potency topical corticosteroids (hydrocortisone 1–2.5%) twice daily to affected facial areas during flares, reserving potent or very potent steroids for other body sites only. 1, 2

Core Treatment Strategy

Daily Emollient Therapy (Foundation of All Management)

• Apply emollients liberally and frequently to all facial skin, even when clear, to restore barrier function and prevent flares. 1, 2
• Apply immediately after bathing (within 10–15 minutes on damp skin) to create a surface lipid film that reduces transepidermal water loss. 1
• Replace regular soaps with soap-free cleansers or dispersible creams, because standard soaps strip natural lipids and worsen barrier dysfunction. 1, 2
• Continue aggressive emollient use during clear periods—this provides steroid-sparing benefits and extends remission. 1

Topical Corticosteroid Selection for Facial Flares

• Use only low-potency topical corticosteroids (hydrocortisone 1–2.5%, aclometasone, or desonide) on facial skin because the face is uniquely thin and highly prone to atrophy, telangiectasia, and other steroid-induced adverse effects. 1
• Apply no more than twice daily to affected areas during active flares. 1
• Use the lowest potency that achieves control—never escalate to potent or very potent preparations on the face. 1
• Limit continuous application to 2–4 weeks, then implement "steroid holidays" or step down to proactive maintenance. 1

Proactive Maintenance After Flare Resolution

• After achieving clearance with topical corticosteroids, transition to twice-weekly application of the same low-potency steroid to previously affected facial areas to prevent relapse—this reduces flare risk from 58% to 25%. 1, 2, 3
• Continue daily emollient use to all facial skin during maintenance. 1, 2
• Topical calcineurin inhibitors (tacrolimus 0.03% or pimecrolimus 1%) may be used 2–3 times weekly as an alternative proactive maintenance strategy if steroid-related concerns exist. 1

Managing Secondary Complications

Bacterial Superinfection

• Monitor for crusting, weeping, purulent exudate, or pustules—these indicate secondary Staphylococcus aureus infection. 1, 2
• Prescribe oral flucloxacillin (or erythromycin for penicillin allergy) while continuing topical corticosteroids concurrently—do not withhold anti-inflammatory therapy during infection. 1
• Obtain bacterial cultures if the skin fails to improve after initial antibiotic treatment. 1

Eczema Herpeticum (Medical Emergency)

• Recognize grouped vesicles, punched-out erosions, or sudden deterioration with fever as eczema herpeticum—this is a medical emergency requiring immediate antiviral therapy. 1, 2
• Start oral acyclovir immediately; use intravenous acyclovir for febrile or systemically ill patients. 1

Adjunctive Measures

Pruritus Control

• Sedating antihistamines (hydroxyzine, diphenhydramine) may improve nighttime itching through their sedative effect, not direct antipruritic action. 1, 2
• Non-sedating antihistamines have no proven benefit in atopic dermatitis and should not be prescribed. 1, 2

Patient Education to Prevent Undertreatment

• Educate patients that low-potency topical corticosteroids (hydrocortisone 1–2.5%) are safe for facial use when applied correctly—steroid phobia often leads to undertreatment. 1
• Explain the difference between low-potency (safe for face) and potent/very potent preparations (never for face). 1

Critical Pitfalls to Avoid

• Never use potent or very potent corticosteroids on facial skin—the thin epidermis makes atrophy and telangiectasia highly likely. 1
• Do not apply topical corticosteroids continuously without breaks—implement twice-weekly maintenance after clearance instead of daily indefinite use. 1
• Do not delay or withhold topical corticosteroids when bacterial infection is present—they remain primary treatment when appropriate systemic antibiotics are given concurrently. 1
• Avoid alcohol-containing products on facial skin. 1

When to Refer or Escalate

• Failure to respond to low-potency topical corticosteroids after 4 weeks of appropriate use. 1, 2
• Diagnostic uncertainty or atypical presentation. 2
• Need for systemic therapy (phototherapy, oral immunosuppressants, biologics). 1
• Suspected eczema herpeticum (urgent referral). 1, 2