What is the recommended topical steroid for dermatitis involving the skin under the eye?

Topical Steroid Selection for Eyelid Dermatitis

For dermatitis involving the skin under the eye, 1% hydrocortisone ointment is the recommended topical steroid for short-term use (less than 8 weeks), applied sparingly to minimize complications. 1

First-Line Treatment Options

Topical Corticosteroids

• Low-potency steroids only:
  • 1% hydrocortisone ointment (preferred formulation)
  • Apply sparingly once or twice daily
  • Maximum duration: 8 weeks
  • Avoid medium or high-potency steroids around the eyes

Alternative First-Line Options

• Topical calcineurin inhibitors (TCIs):
  • Tacrolimus 0.1% ointment: Apply once daily to external eyelids and lid margins for 2-4 weeks (89% response rate) 1
  • Pimecrolimus 1% cream: Effective for mild-to-moderate dermatitis with 71% clearance rate in sensitive areas 1

Advantages of TCIs over Topical Steroids for Periocular Use

Feature	TCIs (Tacrolimus/Pimecrolimus)	Hydrocortisone
Risk of skin atrophy	None	Significant risk with prolonged use [2]
Risk of glaucoma/cataracts	None	Potential risk with periocular application [1]
Side effects	Transient burning/stinging	Skin atrophy, telangiectasia, rebound flares [2]
Duration of use	Safe for longer-term use	Limited to short courses only [1]

Treatment Algorithm

1. Initial Assessment:

   • Determine severity (mild, moderate, severe)
   • Check for signs of infection
   • Evaluate extent of involvement

2. Mild to Moderate Eyelid Dermatitis:

   • First choice: 1% hydrocortisone ointment applied sparingly once or twice daily for up to 2 weeks 1
   • Alternative: Tacrolimus 0.1% ointment or pimecrolimus 1% cream once daily 1

3. Moderate to Severe Eyelid Dermatitis:

   • Short course (5-7 days) of 1% hydrocortisone ointment
   • Transition to tacrolimus 0.1% ointment for maintenance 1
   • Consider preservative-free ocular lubricants 2-4 times daily for associated dry eye 1

4. Adjunctive Measures:

   • Gentle eyelid cleansing with warm compresses once or twice daily 1
   • Preservative-free hyaluronate drops 2-4 times daily for dry eye symptoms 1
   • Avoid potential irritants and allergens

Important Cautions

• Avoid medium and high-potency steroids around the eyes due to increased risk of complications including glaucoma, cataracts, and skin atrophy 3, 2
• Limit duration of topical steroid use to prevent complications such as atrophy and telangiectasia of the eyelids 2
• Monitor for signs of steroid-induced complications including skin thinning, telangiectasia, and rebound dermatitis 4
• Consider intermittent therapy rather than continuous application to reduce risk of adverse effects 2
• Avoid occlusion when applying steroids to periocular skin 5

When to Refer to Ophthalmology

• Urgent referral (within 1 week) for:
  • Severe eyelid involvement
  • Visual changes or corneal involvement
  • Children under 7 years of age 1
• Standard referral for:
  • Cases not responding to initial therapy after 2-4 weeks
  • Cases requiring prolonged topical corticosteroid use 1

Special Considerations

• Infection: If bacterial infection is suspected, consider flucloxacillin or erythromycin (for penicillin-allergic patients) 1
• Herpes simplex infection: Use oral acyclovir early in the course; avoid tacrolimus in patients with history of ocular herpes simplex 1
• Children: Use lower potencies and shorter durations of topical steroids 5
• Chronic management: Consider proactive, intermittent application of tacrolimus (twice weekly) for maintenance after initial clearance 1

The periocular region is particularly vulnerable to steroid-induced side effects due to the thin skin. While 1% hydrocortisone is the safest topical steroid option, topical calcineurin inhibitors offer an effective steroid-sparing alternative with a superior safety profile for this sensitive area.