What is the treatment for peri-orbital dermatitis?

Treatment of Periorbital Dermatitis

The most effective treatment for periorbital dermatitis involves identifying and eliminating the causative agent, followed by topical calcineurin inhibitors as first-line therapy, with oral tetracyclines reserved for more severe or refractory cases. 1

Diagnosis and Causes

Periorbital dermatitis presents as an inflammatory condition affecting the skin around the eyes. Common causes include:

• Allergic contact dermatitis (most common: 31-44%)
• Atopic eczema (14-25%)
• Airborne contact dermatitis (2-10%)
• Irritant contact dermatitis (8-9%) 2, 3

Less common causes include periorbital rosacea, allergic conjunctivitis, and psoriasis vulgaris. Risk factors include female gender, atopic skin diathesis, and age over 40 years 3.

Treatment Algorithm

Step 1: Identify and Eliminate Triggers

• Conduct patch testing to identify relevant allergens
• Common triggers include:
  • Leave-on cosmetic products (face creams, eye shadow)
  • Eye drops containing fragrances, preservatives, and drugs
  • Medications (e.g., apixaban has been reported to cause periorbital dermatitis) 4
• Discontinue use of topical corticosteroids on the face if present
• Replace soaps and detergents with gentle emollients 1

Step 2: First-Line Treatment

• Topical calcineurin inhibitors (TCIs):
  • Tacrolimus 0.03-0.1% ointment applied twice daily for 1-4 weeks 5
  • Safe and effective for periorbital dermatitis, especially in atopic dermatitis 1, 5
  • Can be applied directly to the ocular surface of the lids for best effect (typically initiated by ophthalmology) 6
  • For children: Start with tacrolimus 0.03% ointment; may increase to 0.1% in appropriate cases 6

Step 3: For Moderate to Severe Cases

• Short-term topical corticosteroids:

  • Preservative-free dexamethasone 0.1% for up to 8 weeks maximum 6
  • Triamcinolone cream has shown effectiveness with less than 30% of patients being refractory 7
  • Note: Hydrocortisone has shown poor efficacy with over 80% of patients experiencing refractory episodes 7

• Oral tetracyclines:

  • Effective for perioral/periorbital dermatitis
  • Contraindicated in children under 8 years and pregnant women 1

Step 4: For Resistant Cases

• Combination therapy:

  • Consider combination of topical corticosteroids, tacrolimus ointment, and ciclosporin drops 6
  • For cases with hyperpigmentation, consider azelaic acid (15-20%) or kojic acid 1

• Adjunctive measures:

  • Lid hygiene with specially designed warming devices (not hot flannels)
  • Eyelid massage to soften oils
  • Cleaning eyelid margins with bicarbonate solution or commercial lid wipes 6
  • Preservative-free ocular lubricants 6
  • Antihistamine eye drops for cases with allergic component 6

Common Pitfalls and How to Avoid Them

• Prolonged use of topical corticosteroids: Can cause or worsen periorbital dermatitis with risk of rebound when stopped. Limit use to 8 weeks maximum 6, 1

• Inadequate allergen identification: Ensure thorough patch testing, including patients' own products (12.5% of allergic periocular dermatitis cases are only identified this way) 3

• Premature discontinuation: Treatment often requires several weeks of consistent therapy; follow up every 4-6 weeks to assess response 1

• Neglecting sun protection: Implement strict broad-spectrum SPF 70+ 1

• Overtreatment: Avoid aggressive therapies such as high-concentration peels or laser treatments that can worsen the condition 1

Follow-up and Prognosis

• Follow-up every 4-6 weeks to assess treatment response
• Prognosis varies, with only 25% of patients with occupational contact dermatitis completely healing over a 10-year period, while 50% continue to have intermittent symptoms 1
• Long-term management strategies and patient education are crucial for optimal outcomes

For refractory cases, consider referral to a dermatologist specializing in patch testing or a multidisciplinary approach including ophthalmology for comprehensive care 1, 7.