How to treat peri-orbital dermatitis?

Treatment of Periorbital Dermatitis

Topical calcineurin inhibitors are the first-line therapy for periorbital dermatitis, particularly tacrolimus ointment for adults and pimecrolimus for children. 1, 2

Diagnosis and Classification

• Periorbital dermatitis presents as erythematous papules, pustules, and papulovesicles around the eyes, often with significant discomfort due to its visible location 1
• Common causes include allergic contact dermatitis (32-44%), atopic eczema (14-25%), airborne contact dermatitis (2-10%), and irritant contact dermatitis (8-9%) 1
• Less common causes include periorbital rosacea, allergic conjunctivitis, or psoriasis vulgaris 1
• Risk factors include female gender, atopic skin diathesis, and age over 40 years 1

First-Line Treatment

• For atopic eczema and other forms of periorbital dermatitis:

  • Tacrolimus 0.1% ointment applied once daily to external eyelids including lid margins for 2-4 weeks (adults) 2, 1
  • Tacrolimus 0.03% ointment for children aged 2-15 years 3
  • Pimecrolimus 1% cream is an alternative for children and those who cannot tolerate tacrolimus 3, 4

• For allergic contact dermatitis:

  • Identify and eliminate relevant allergens (common culprits include fragrances, preservatives in cosmetics, and eye drops) 1
  • Patch testing may be necessary to identify specific allergens 1

Second-Line Treatments

• For moderate-to-severe cases:

  • Short-term topical corticosteroids (maximum 8 weeks) such as preservative-free dexamethasone 0.1% 3
  • Triamcinolone cream shows lower rates of refractory disease (less than 30%) compared to hydrocortisone (over 80% refractory cases) 5
  • Transition to steroid-sparing agents (tacrolimus, pimecrolimus) as soon as possible to avoid rebound 3, 4

• For periorbital hyperpigmentation:

  • Chemical peeling with TCA 3.75% and lactic acid 15% combination (multiple sessions at 2-4 week intervals) 2, 3
  • PRP (platelet-rich plasma) treatments (3-4 sessions at 2-4 week intervals) 3, 2
  • Carboxytherapy (weekly sessions) 3

Management Principles

• Avoid potential irritants:

  • Discontinue topical corticosteroids on the face if they preceded the condition 6, 4
  • Avoid skin irritants such as perfumes, deodorants, alcohol-based lotions 3
  • Remove cosmetics, soaps, and other potential allergens 1

• Supportive measures:

  • Gentle skin care and application of emollients 3
  • Keep the affected area clean and dry 3
  • Avoid scratching the affected area 3

Special Considerations

• For eyelid involvement:

  • Preservative-free formulations are recommended due to increased risk of allergic contact dermatitis 3
  • Lid hygiene and ocular lubricants for associated ocular surface symptoms 3
  • Antihistamine drops can be added for mild-to-moderate cases with allergic components 3

• For refractory cases:

  • Consider combination therapy (chemical peeling + PRP) 2
  • Evaluate for undiagnosed contact allergens through patch testing 1
  • Consider oral tetracyclines for adults (not suitable for children under 8 years) 6, 4

Treatment Duration and Follow-up

• Most treatments require multiple sessions over weeks to months 2
• Monitor for potential side effects of topical corticosteroids (glaucoma, cataracts) with baseline and periodic IOP measurements if used 3
• For calcineurin inhibitors, monitor for potential development of skin cancer or lymphoma (rare side effect) 3

Common Pitfalls

• Overuse of topical corticosteroids can worsen the condition or cause rebound dermatitis 6, 4
• Failure to identify and eliminate contact allergens will result in persistent symptoms 1
• Hydrocortisone has high rates of refractory disease (over 80%) and should be avoided 5
• Greasy topical products should be avoided as they can promote superinfection 3