What is the appropriate treatment for eczema of the nasal folds?

Treatment of Eczema in the Nasal Folds

For eczema affecting the nasal folds, use a low-potency topical corticosteroid (hydrocortisone 1–2.5% cream) applied twice daily for 2–4 weeks, combined with liberal emollient therapy, because the facial skin—particularly around the nose—is thin and highly susceptible to steroid-induced atrophy. 1

Why Low-Potency Steroids Are Essential for This Location

• The nasal fold area has uniquely thin skin that makes it prone to corticosteroid-induced atrophy, telangiectasia, and other adverse effects when potent or very potent steroids are used 1
• Hydrocortisone 1–2.5% delivers sufficient anti-inflammatory activity while minimizing the risk of skin thinning in this sensitive facial region 1
• Potent or very potent corticosteroids must be avoided in thin-skinned areas including the face, neck, and flexures where atrophy risk is highest 1

Application Strategy

• Apply the low-potency corticosteroid no more than twice daily to affected nasal fold areas 2
• Limit continuous application to 2–4 weeks maximum, then implement "steroid holidays" or step down to maintenance therapy 1
• After initial clearance, consider proactive maintenance with the same low-potency steroid applied twice weekly to previously involved skin to prevent recurrence 1, 3

Essential Adjunctive Emollient Therapy

• Apply emollients liberally and frequently to the nasal fold area, even when eczema appears controlled, because they restore barrier function and reduce the need for steroids 1, 4
• Apply emollients immediately after bathing or face-washing to create a surface lipid film that limits transepidermal water loss 2, 1
• Use soap-free cleansers and avoid alcohol-containing products on the face, as regular soaps strip natural lipids and worsen barrier dysfunction 1

Watch for Secondary Infection

• Monitor for crusting, weeping, or pustules in the nasal folds, which indicate secondary bacterial infection (most commonly Staphylococcus aureus) 2, 1
• If bacterial infection is confirmed, prescribe oral flucloxacillin (or erythromycin for penicillin allergy) while continuing the topical corticosteroid—do not withhold steroids during appropriate antibiotic therapy 1, 5
• Be alert for grouped vesicles or punched-out erosions, which suggest eczema herpeticum (a medical emergency requiring immediate oral or IV acyclovir) 2, 1

Managing Pruritus

• For nighttime itching that disrupts sleep, prescribe sedating antihistamines (hydroxyzine or diphenhydramine) at bedtime, understanding their benefit is purely sedative rather than antipruritic 1
• Do not prescribe non-sedating antihistamines, as they have no proven benefit in atopic eczema 1

Common Pitfalls to Avoid

• Never use potent or very potent corticosteroids on the nasal folds—this thin facial skin will develop atrophy, telangiectasia, and other irreversible changes 1, 6
• Do not apply topical corticosteroids continuously without breaks; implement regular "steroid holidays" to reduce adverse effects 2, 1
• Address "steroid phobia" directly by educating patients that low-potency topical corticosteroids (hydrocortisone 1–2.5%) are safe for facial use when applied correctly, to prevent undertreatment 1
• Keep fingernails short to minimize skin trauma from scratching 2

When to Escalate or Refer

• If the nasal fold eczema does not respond to low-potency topical corticosteroids after 4 weeks of appropriate use, refer to dermatology 1
• Refer immediately if eczema herpeticum is suspected (grouped vesicles, punched-out erosions, systemic symptoms) 1
• Consider dermatology consultation for atypical presentations or diagnostic uncertainty 1