What is the appropriate evaluation and initial management for a 44-year-old woman presenting with an itchy rash localized to the face and neck?

Evaluation and Management of Itchy Rash on Face and Neck in a 44-Year-Old Woman

Begin with low-potency topical corticosteroid (hydrocortisone 1–2.5% cream) applied twice daily to the affected areas, combined with liberal emollient use, while actively excluding secondary bacterial or viral infection.

Immediate Clinical Assessment

Look for specific features that distinguish the underlying diagnosis:

• Crusting, weeping, or pustules indicate secondary bacterial infection (most commonly Staphylococcus aureus) 1
• Grouped vesicles or punched-out erosions suggest eczema herpeticum—a medical emergency requiring immediate antiviral therapy 1, 2
• Greasy, yellow scales in nasolabial folds and eyebrows point toward seborrheic dermatitis rather than atopic eczema 3
• Well-demarcated, thick silvery plaques favor psoriasis over eczema 3
• Sharp demarcation corresponding to contact area suggests allergic contact dermatitis 1

Obtain a focused history addressing:

• Aggravating factors (new cosmetics, fragrances, preservatives, occupational exposures) 1
• Personal or family history of atopy (asthma, hay fever, childhood eczema) 1
• Sleep disturbance from itching 1
• Previous treatments and their effectiveness 1

First-Line Treatment Protocol

Topical corticosteroid application:

• Apply hydrocortisone 1–2.5% cream to face and neck no more than twice daily for 2–4 weeks 2, 4
• The facial skin is uniquely thin and prone to steroid-induced atrophy and telangiectasia; therefore, avoid medium- or high-potency steroids (triamcinolone, mometasone, clobetasol) on the face entirely 2, 3
• After initial clearance, implement "steroid holidays" or switch to twice-weekly maintenance application to previously affected areas to prevent relapse 1, 2

Essential adjunctive emollient therapy:

• Apply fragrance-free emollients liberally throughout the day, especially immediately after bathing to damp skin, to create a surface lipid film that reduces transepidermal water loss 1, 2
• Use soap-free cleansers or dispersible creams as soap substitutes; regular soaps strip natural lipids and worsen barrier dysfunction 1, 2
• Avoid all alcohol-containing preparations on the face, as they significantly worsen dryness and trigger flares 3

Pruritus management:

• Sedating antihistamines (hydroxyzine, diphenhydramine) may improve nighttime itching through their sedative properties, not direct antipruritic effects 2
• Non-sedating antihistamines have no proven benefit in atopic eczema and should not be used 2
• Keep fingernails short to minimize skin trauma from scratching 1, 2

Management of Secondary Infection

If bacterial infection is suspected (crusting, weeping, increased erythema):

• Prescribe oral flucloxacillin as first-line antibiotic for S. aureus (or erythromycin if penicillin allergy) 2
• Continue topical corticosteroids concurrently with systemic antibiotics—do not withhold anti-inflammatory therapy during infection 2
• Obtain bacterial swabs if no improvement after initial antibiotic course 1

If eczema herpeticum is suspected (grouped vesicles, punched-out erosions, fever):

• This is a medical emergency 2
• Start oral acyclovir immediately; use intravenous acyclovir if patient is febrile or systemically ill 2
• Send swabs for virological screening and electron microscopy 1

When to Escalate or Refer

Refer to dermatology if:

• No improvement after 4 weeks of appropriate topical corticosteroid therapy 2
• Diagnostic uncertainty or atypical presentation 2, 3
• Need for systemic therapy (phototherapy, immunosuppressants, biologics) 1, 2
• Suspected contact dermatitis requiring patch testing 1
• Recurrent severe flares despite optimal maintenance therapy 2

Critical Pitfalls to Avoid

• Do not delay topical corticosteroids when infection is present—they remain primary treatment when appropriate systemic antibiotics are given concurrently 2
• Do not use very potent or potent corticosteroids on the face—the thin skin is highly susceptible to atrophy, telangiectasia, and tachyphylaxis 1, 2, 3
• Do not continue ineffective treatment indefinitely—escalate after 4 weeks if no response 2
• Address "steroid phobia" by explaining different potencies and the safety of low-potency preparations for facial use 2, 4
• Avoid undertreatment—even mild eczema can cause severe morbidity and quality-of-life impairment 1

Alternative Considerations

If seborrheic dermatitis is suspected (greasy yellow scales in nasolabial folds, eyebrows):

• Add ketoconazole 2% cream once or twice daily to affected areas 3
• Consider ketoconazole 2% shampoo if scalp is involved 3
• Limit topical corticosteroid use to 2–4 weeks maximum due to facial location 3

If contact dermatitis is suspected:

• Identify and eliminate potential allergens (fragrances, preservatives like methylchloroisothiazolinone, propylene glycol in topical products) 1
• Consider patch testing if history suggests allergic trigger 1