Facial eczema treatment in the UK

Is the rash definitely eczema?

Atopic eczema causes itching with dry, cracked, scaly or thickened skin. Inflamed patches can look red, purple, grey, lighter or darker than surrounding skin, so redness is not the only sign to look for. Facial eczema is particularly common in babies and toddlers, although eczema can start at any age. A GP should assess a new suspected eczema rash rather than treating every dry facial patch as the same condition.3

Atopic eczema and contact dermatitis are different possibilities: contact dermatitis deserves consideration when the pattern changes, treatment is not helping, or a treatment appears to cause another reaction. Tell your GP about products that seem to worsen the rash. If there is no itch, atopic eczema is less likely.1

How should you wash and moisturise your face?

1. 1Wash with a suitable emollient or emollient soap substitute instead of ordinary soap. Mix a small amount with warm water in your palm and spread over damp or dry skin.
2. 2Rinse, then pat dry without rubbing. An emollient wash does not need to foam to clean, despite soap's long career in special effects.
3. 3Apply your emollient straight after drying. Smooth it gently in the direction of hair growth rather than rubbing vigorously.
4. 4Moisturise at least twice daily, including when the eczema improves. Three or four applications daily can help keep exposed facial skin moisturised; reapply when it feels dry or tight.
5. 5If you also use prescribed skin treatment, leave 20 to 30 minutes between applications. Ask your prescriber which product to apply first rather than mixing them together.

Which moisturiser should you choose?

Creams absorb quickly and are less greasy, making them useful during the day, which gives the word cream something practical to do. Ointments are thicker and more moisturising for very dry skin, particularly at night, but should not be used on weeping eczema. Lotions spread easily but are less moisturising, which makes easy spreading a slightly incomplete sales pitch. You can use different textures rather than expecting one product to handle every situation, which is a lot of responsibility to put in a tub. Emollients are available from pharmacies without a prescription.4

Avoid aqueous cream as a moisturiser because it can irritate eczema. If an emollient causes persistent burning or stinging, inflamed hair follicles or a worsening facial rash, ask a pharmacist, nurse or GP about changing it. Use a clean spoon or pump rather than fingers in a tub. Keep away from flames and cigarettes: fabrics carrying emollient residue catch fire more easily, even after washing.34

Can you use hydrocortisone on your face?

A prescriber can choose a mild steroid such as hydrocortisone 1% for facial inflammation. Do not move a steroid prescribed for your body onto your face without approval. Facial skin, especially the eyelids, is more prone to steroid side effects. The percentage on a tube does not let you compare the potency of different steroid medicines.15

Topical steroids are usually applied once or twice daily, but follow your prescription for the exact frequency and course length. Use enough to cover the affected area; ask for a demonstration using fingertip units, a way to measure the amount of cream or ointment. Using too little can prolong treatment. Correctly used steroids are safe and effective; excessive use can cause skin thinning and colour changes. Return to your prescriber if treatment makes the rash worse or does not help.5

What if facial eczema keeps coming back?

Tacrolimus and pimecrolimus are topical calcineurin inhibitors, medicines applied to the skin to reduce inflammation. They are useful alternatives for facial eczema that has not responded adequately to steroid treatment, including treatment around the eyelids. A clinician can also prescribe intermittent maintenance treatment to reduce recurring flares. Initial stinging often improves with continued use. These medicines should not be used on infected eczema. The medicine, strength and schedule need to match the patient's age and treatment plan.26

What improvement should you expect?

Treatment aims to calm itching and inflammation and improve the damaged skin barrier, not permanently cure eczema. Regular emollient use can reduce the need for stronger topical steroids. Many children improve as they grow older, but flares can return in adulthood after years of clear skin. A flare does not necessarily mean you missed a treatment or can identify a particular trigger. Keep a supply of prescribed treatments available because breaks in treatment can allow symptoms to flare.6

What can make facial eczema worse?

Soap, irritants, allergens, heat, temperature changes, stress and skin infections can worsen eczema. Avoid triggers you have noticed and keep cool if heat increases itching. Keep nails short to limit damage from scratching. Do not cut foods out of your diet, or change your diet while breastfeeding a baby with eczema, unless a doctor advises it. Hormonal changes during pregnancy can worsen eczema.3

How does treatment differ for babies and children?

Children need an individual treatment plan, including clear instructions about which cream goes where and how much to apply. Potent and very potent steroids are rarely used on children's faces. Smooth creams gently rather than rubbing them in vigorously, which can increase itching. A thinner emollient before school and a thicker one at night can make treatment easier to fit into daily life. Antihistamines generally have limited effects on eczema symptoms; sedating versions are sometimes used briefly at night, with attention to next day tiredness.6

What if symptoms return after stopping a steroid?

If symptoms return within two weeks, do not restart the steroid without consulting your prescriber unless your treatment plan already covers this. Seek advice for burning, peeling, oozing sores or colour changes spreading beyond the treated area. Topical steroid withdrawal reactions are thought to be rare and are usually associated with frequent or prolonged use of strong steroids. Ask for a treatment review if you have been using a steroid continuously for a long time.5

When do you need urgent medical help?

Ask for an urgent GP appointment or contact NHS 111 if eczema becomes painful, swollen, warm, blistered, crusty, leaks fluid or develops pus, especially if it suddenly spreads or you feel unwell. Groups of painful blisters that break into shallow sores and spread rapidly can signal eczema herpeticum, an infection caused by the cold sore virus. Suspected eczema herpeticum needs emergency medical assessment and antiviral treatment. Avoid contact with someone who has a cold sore.1367

Infection can sometimes explain eczema that is not improving even without obvious pus or crusting. Heavy bacterial infection can require oral antibiotics, but antibiotics are not automatically needed for every suspected infected patch when you are otherwise well. A clinician decides whether treatment or a skin swab is needed.27

Where can you get treatment in the UK?

A pharmacist can advise on small, mildly itchy dry patches. See a GP for more severe eczema or treatment that is not helping. Dermatology referral is appropriate when several treatments have failed, eczema is severe despite treatment, or it is affecting mental health. Tell the clinician about disturbed sleep and effects on daily life as well as the visible rash.23