The redness, dry skin, and itching caused by atopic dermatitis (AD) — more commonly known as eczema — can be life-altering. These symptoms can be even more difficult to deal with when they occur on the face. People with facial AD not only have to manage the discomfort of the condition, but they also have to deal with the psychological and social effects of eczema on the most visible part of the body. In addition, attempts to conceal eczema with cosmetics or topical treatments can make symptoms worse.

To understand the best ways to manage symptoms of eczema when they occur on the face, MyEczemaTeam had an in-depth conversation with Dr. Brian Kim. Dr. Kim is an associate professor of dermatology, anesthesiology, pathology, and immunology, and serves as co-director of the Center for the Study of Itch and Sensory Disorders at Washington University School of Medicine in St. Louis, Missouri. His research on the immune regulation of AD and itch has led to awards and funding from the National Institutes of Health (NIH), the Doris Duke Charitable Foundation, the American Skin Association, the American Academy of Dermatology, and the American Society for Clinical Investigation.

Can makeup, moisturizers, and other cosmetic products cause or worsen facial eczema?

One thing that we don't take into account is that we put a lot of stuff on our skin that we think is completely benign. But if you actually take a look at the ingredients in skin care products, there are so many synthetic ingredients. Even if those ingredients don’t elicit a reaction, on some level they are still irritants, including the ingredients in cosmetics. I think what is happening to a lot of people with facial eczema is just repeated environmental exposure. Like with anything, someday one exposure is the final straw, and people develop a facial eczema that becomes very refractory [difficult to treat].

Does that include sunblock as well?

Sunblock isn't bad, but it also has a lot of ingredients. I think what's happened is that, in people with eczema, the skin is just incredibly sensitized to a lot of environmental agents that act as direct activators of their immune systems. We’ve done research in this area. There are receptors on cells that we call mast cells that are incredibly activated by environmental factors. The immune system is very smart. It’s hard-wired to detect a lot of different compounds and decide, “That's irritating. Let's stay away.”

Are there any common skin conditions that can complicate eczema treatment on the face?

From seeing a lot of patients, I’ve come to find that a lot of people [with eczema also] have rosacea. My theory is that facial eczema is largely complicated by having underlying rosacea — redness and flushing of the skin without necessarily having a rash. A lot of people who have fair skin will have a lot more of this redness. You'll notice that if someone goes for a run, they'll come back with rosy cheeks. That, in some sense, is a form of rosacea. It's just not necessarily pathologic. But over time, you may start to develop more rosacea on the face. A lot of people might not even notice it and say, “Well, I don't have it. I haven't seen a dermatologist.” But they have it. And if you mix rosacea with facial dermatitis, that is a kind of a lethal combination.

The reason why is that redness of the facial skin — we call it erythema — means that your blood vessels are open. When you have rosacea, the blood vessels on your face are permanently open — they've lost the ability to close for whatever reason, and that's where you get the blushing. However, your vascular tone is very important for resolving inflammation in the skin. One of the key mechanisms to get rid of inflammatory cells is to close off the blood vessels. Now, if you can't close those vessels off — if you can't close the pipes off, so to speak — how do you get rid of the inflammation? So I think there's a connection between rosacea and eczema that actually manifests as this kind of refractory, chronic facial dermatitis that we see a lot.

Eczema on the face can be difficult to treat due to side effects of some topical medications, such as corticosteroids. How do you treat facial eczema?

You can use topical steroids as a treatment option [on the face], but you have to be careful, and you have to use a very, very low-potency steroid. I do that all the time. But remember, many people with eczema have used higher-potency therapies, and those have still failed. What I've done is add a mild steroid or even, say, a topical calcineurin inhibitor. And then I add a rosacea treatment. I’ve had people with eczema get much better, because what they're basically doing is just getting rid of any rosacea that they never even thought that they had.

Your rosacea has to be pretty bad for you to want to treat it on its own — it's just a little bit of blush, and it doesn't bother people. But treating rosacea can be all you might need for the rash to go down.

Is facial eczema often difficult to treat? If so, could you explain why?

Unfortunately, a lot of people with facial dermatitis often have had it for years. They've made earnest attempts to treat the condition. However, what's happened to them is that they've gotten to the point where their skin is so sensitive to many allergens. Unfortunately, a lot of people with facial eczema do have to stop using cosmetics and anything that contains any kind of irritants. By that point, they’re so frustrated that they’re often happy to do that. I have very few patients who say, “I have to go back to using cosmetics right away.”

Are there any safe brands you recommend for use with facial eczema?

Every good skin care brand has a lot of products that are tailored to eczema, and brands have gotten better and better at it. The reality is that the fewer ingredients in a moisturizer, the better. For instance, Vaseline (petroleum jelly) is probably still the best substance for moisturizing in the world, but the issue is that it’s incredibly thick and greasy. The skin care industry is a huge industry, but what I say is that every moisturizer is trying to do what Vaseline can do without feeling like Vaseline.

To make lotions the right texture, you actually have to add more ingredients. For most people, that’s fine. But over time, sometimes with aging, your skin changes, and you just can't tolerate those otherwise innocuous substances. And at the end of the day, that's what atopic eczema is. It's a reaction to something that's innocuous in the environment.

Why is it so important to stick to a consistent skin care and treatment plan?

What worries me about eczema is that if you don't take good care of it, it can get worse over time. People also can start to develop some other complications from it. If you have eczema, you're at much more risk for developing allergic contact dermatitis to nickel or other contact allergens, and now your life is more complicated because you have two problems in the same area. So you want to prevent that from happening.

I've had medical issues myself where I wanted to ignore it and hope that it just goes away because I had bigger things to worry about. But you really want to get ahead of eczema.

Is there any other general advice that you give to individuals who come to see you?

The thing about eczema is that its various forms are very debilitating. I think the toll that eczema can take on your life can be much greater than even the problems it's causing on your skin. For example, if you have itchy skin and you're not sleeping, that can lead to sleep disorders, which can have a huge impact on your cardiovascular health. So I think it's very important to take really good care of your skin, so that you don't have other problems related to the rest of your health as well.

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