What is the recommended treatment for eczema involving the skin underneath the eye?

Treatment of Eczema Under the Eye

For eczema involving the skin underneath the eye, tacrolimus 0.1% ointment is the recommended first-line treatment due to its efficacy and safety profile in this sensitive area. 1

First-line Treatment Options

Topical Calcineurin Inhibitors

• Tacrolimus 0.1% ointment: Apply once daily to the affected area for 2-4 weeks
  • Highly effective for periocular eczema with 89% response rate 1
  • Does not cause skin atrophy, making it safer for thin periocular skin 2
  • Can be applied directly to the ocular surface of the lids (though this would typically be initiated by ophthalmology) 1

Considerations for Topical Corticosteroids

• Low-potency corticosteroids (e.g., hydrocortisone 1%):
  • Use only for short-term treatment (3-7 days) if tacrolimus is unavailable
  • Apply sparingly once or twice daily
  • Risk of complications with long-term use including:
    • Skin atrophy and telangiectasia of the eyelids 3
    • Rosacea-like eruptions 3

Adjunctive Treatments

Moisturization

• Apply emollients regularly to maintain skin barrier function 1, 4
• Use fragrance-free, oil-in-water creams or ointments 1
• Avoid alcohol-containing lotions or gels 1

For Associated Symptoms

• Pruritus: Consider oral non-sedating antihistamines (cetirizine, loratadine) 1, 4
• Dry eyes: Use preservative-free artificial tears if tear film instability is present 1

Management of Infection

If bacterial infection is suspected (crusting, weeping, or pustules):

• Obtain bacterial culture 4
• Consider topical antibiotics 4
• For widespread or severe infection, oral antibiotics may be necessary 4

Treatment Algorithm Based on Severity

Mild Eczema

1. Tacrolimus 0.1% ointment once daily
2. Regular emollients
3. Avoid irritants and triggers

Moderate Eczema

1. Tacrolimus 0.1% ointment once daily
2. Consider short course (3-5 days) of low-potency topical corticosteroid if acute flare
3. Regular emollients
4. Oral antihistamines for itch control

Severe or Refractory Eczema

1. Refer to dermatology or ophthalmology
2. Consider cyclosporine eyedrops (to be initiated by ophthalmology) 1
3. Lid hygiene measures may be beneficial 1

Special Considerations

• Children: Use tacrolimus 0.03% ointment instead of 0.1% 1, 5
• Herpes simplex history: Avoid tacrolimus in patients with history of ocular herpes simplex virus 1
• Steroid complications: If signs of steroid-induced complications appear (skin thinning, telangiectasia), discontinue immediately and switch to tacrolimus 3

Monitoring and Follow-up

• Reassess after 2-4 weeks of treatment
• If no improvement or worsening occurs, refer to ophthalmology or dermatology
• For patients using tacrolimus, arrange ophthalmology review within 4 weeks 1

Pitfalls to Avoid

• Prolonged use of topical corticosteroids around the eyes can lead to skin thinning and telangiectasia 3
• Undertreatment due to "steroid phobia" - educate patients about proper use of medications 1
• Failure to identify and address secondary infection
• Not allowing adequate time for treatment to work - a minimum of 2-4 weeks is often needed 1

Remember that the periocular skin is particularly thin and sensitive, making it more susceptible to adverse effects from topical corticosteroids. Tacrolimus offers a safer alternative with proven efficacy for this delicate area.