What is the treatment for eyelid eczema?

Treatment for Eyelid Eczema

Tacrolimus 0.1% ointment is the first-line treatment for eyelid eczema, applied once daily to the external eyelids and lid margins for 2-4 weeks. 1

First-Line Treatment Options

Topical Calcineurin Inhibitors

• Tacrolimus ointment (preferred):
  • For adults: 0.1% strength applied once daily 1
  • For children (2-17 years): Start with 0.03% strength, can increase to 0.1% if needed (under ophthalmology guidance) 1
  • Apply to external eyelids and lid margins
  • Duration: 2-4 weeks
  • Efficacy: 89% response rate in clinical studies 1
  • Caution: May cause temporary burning/itching with initial applications 2
  • Contraindication: History of ocular-surface herpes simplex virus or varicella zoster virus 1

Topical Corticosteroids

• Short-term use only for moderate-to-severe cases:
  • Preservative-free dexamethasone 0.1% (for moderate-to-severe cases)
  • Maximum duration: 8 weeks 1
  • Efficacy: 74% response rate 1
  • Risk: Prolonged use can cause skin atrophy and telangiectasia of the eyelids 3
  • Should be tapered as soon as possible and replaced with steroid-sparing agents 1

Adjunctive Treatments

Lubricants

• Preservative-free formulations recommended (65% response rate) 1, 4
• Apply multiple times daily
• Particularly useful for associated dry eye symptoms

Lid Hygiene Measures

• For patients with blepharitis or lid margin disease (50% response rate) 1
• Use specially designed warming devices (not hot flannels)
• Follow with eyelid massage and cleaning
• Can use commercially available lid wipes or homemade bicarbonate solution
• Not recommended for children 1

Topical Ciclosporin Eyedrops

• For severe cases not responding to other treatments (63% response rate) 1
• Usually initiated by ophthalmologists
• May be suitable for dermatologists to prescribe under agreed local pathways

Treatment Algorithm

1. Initial Assessment:

   • Evaluate severity of eyelid eczema
   • Check for signs of infection
   • Rule out contact allergic dermatitis

2. Mild to Moderate Cases:

   • Start with tacrolimus 0.1% ointment once daily (0.03% for children)
   • Add preservative-free lubricants
   • Implement lid hygiene measures if blepharitis is present

3. Moderate to Severe Cases:

   • Short course of topical corticosteroids (preservative-free dexamethasone 0.1%)
   • Transition to tacrolimus ointment as maintenance therapy
   • Consider ophthalmology referral if no improvement after 4 weeks

4. Treatment-Resistant Cases:

   • Refer to ophthalmology
   • Consider combination therapy with topical corticosteroids, tacrolimus ointment, and ciclosporin drops
   • Consider patch testing if contact dermatitis is suspected 4

Important Considerations

• Monitoring: Arrange ophthalmology review within 4 weeks when using tacrolimus ointment 1
• Safety: Tacrolimus ointment does not significantly affect intraocular pressure, unlike corticosteroids 5
• Duration: Corticosteroids should be limited to short-term use (2-4 weeks) to avoid side effects 4, 6
• Application technique: For tacrolimus, the ointment can be applied directly to the ocular surface of the lids for best effect (off-license use), but this should typically be initiated by ophthalmology 1

Pitfalls and Caveats

• Avoid prolonged use of topical corticosteroids on eyelids due to risk of skin atrophy, telangiectasia, and increased intraocular pressure 3
• Be aware that pimecrolimus is less effective than tacrolimus for eczema treatment 7
• Watch for signs of ocular herpes infection, which is a contraindication for tacrolimus use 1
• Discontinue lid hygiene measures if eye symptoms worsen 1
• Ensure proper application technique is demonstrated to patients for optimal efficacy