What is the treatment for ocular dermatitis?

Treatment of Ocular Dermatitis

The first-line treatment for ocular dermatitis is tacrolimus 0.1% ointment applied once daily to the external eyelids and lid margins for 2-4 weeks, with preservative-free ocular lubricants as adjunctive therapy. 1

Treatment Algorithm Based on Age and Severity

For Adults:

Mild Disease

1. First-line treatment:

   • Preservative-free ocular lubricants 2-4 times daily 2
   • Gentle lid cleansing using diluted baby shampoo or commercial eyelid cleaners 1

2. If inadequate response:

   • Add topical antihistamine eyedrops (e.g., olopatadine twice daily) 2
   • For blepharitis subtype: Add warm compresses using specially designed devices or microwaveable eyelid warming devices, followed by eyelid massage 2

3. If still inadequate:

   • Tacrolimus 0.1% ointment once daily to lid margins 1
   • Refer to ophthalmology if no improvement after 4 weeks 2

Moderate to Severe Disease

1. Initial treatment:

   • Preservative-free ocular lubricants 2-4 times daily 2
   • Tacrolimus 0.1% ointment once daily to lid margins 2, 1
   • Consider topical antihistamine eyedrops 2

2. If inadequate response:

   • Refer to ophthalmology for consideration of short-term topical corticosteroids (preservative-free dexamethasone 0.1%) 2
   • Maximum duration of topical corticosteroids: 8 weeks 2
   • Early introduction of corticosteroid-sparing agents (ciclosporin drops) 2

3. For treatment-resistant cases:

   • Consider combination of tacrolimus ointment and ciclosporin drops 2
   • Consider patch testing for identification of contact allergens 2

For Children:

Under 7 years:

• Refer to ophthalmology regardless of severity due to risk to neuro-ocular development 2
• Preservative-free ocular lubricants as initial therapy while awaiting ophthalmology assessment 2
• Tacrolimus 0.03% (not 0.1%) should be used if recommended by ophthalmologist 1
• Warm compress regimens not recommended 2

7-17 years:

• Mild to moderate: Same as adults, but refer to ophthalmology if no response to lubricants or antihistamine drops 2
• Severe: Urgent ophthalmology referral (within 4 weeks) 2
• Tacrolimus use should follow ophthalmology advice 2

Important Considerations

Topical Corticosteroids

• Use the least potent preparation required to control symptoms 1
• Apply no more than twice daily 1
• Short-term use only (maximum 8 weeks) 2
• Risk of increased intraocular pressure and cataracts with long-term use 1
• Hydrocortisone can be used for children over 2 years of age, no more than 3-4 times daily 3

Referral Indications

• Children under 7 years: All cases 2
• Children 7-17 years: Non-response to initial therapy or severe disease 2
• Adults: Severe disease or non-response to topical treatment and lid hygiene 2
• Progressive loss of visual acuity 2
• Suspected bacterial or viral infections 1

Avoiding Triggers

• Discontinue suspected allergens (common culprits: eye drops, creams/lotions, cosmetics) 4
• Avoid wool clothing, extreme temperatures, harsh soaps 1
• Use preservative-free formulations due to increased risk of allergic contact dermatitis 2, 1

Special Considerations for Dupilumab-Related Ocular Surface Disorders (DROSD)

If ocular dermatitis is related to dupilumab therapy:

• Consider dose reduction in patients with good skin control 2
• Consider withdrawal of dupilumab if there is:
  • Progressive loss of visual acuity unresponsive to treatment
  • Need for prolonged ocular topical corticosteroid therapy (>8 weeks)
  • Significant impact on quality of life 2

Common Pitfalls to Avoid

1. Using preserved eye drops or ointments, which can exacerbate allergic contact dermatitis 2, 1
2. Prolonged use of topical corticosteroids around the eyes 1
3. Using hot flannels for warm compresses (risk of scalding) 2
4. Failing to identify and eliminate causative agents 4
5. Delaying ophthalmology referral for children under 7 years 2
6. Overlooking bacterial or viral infections that may require specific treatment 2
7. Not considering patch testing in treatment-resistant cases 2, 5

By following this structured approach based on age and severity, most cases of ocular dermatitis can be effectively managed with good outcomes for vision and quality of life.