What is the treatment for perioral dermatitis around the eyes?

Treatment of Perioral Dermatitis Around the Eyes

For perioral dermatitis around the eyes, the first-line treatment is preservative-free ocular lubricants combined with tacrolimus 0.1% ointment applied once daily to the external eyelids and lid margins for 2-4 weeks. 1, 2

First-Line Treatment Options

• Preservative-free ocular lubricants (hyaluronate drops) should be applied 2-4 times daily as initial therapy for all cases of periorbital dermatitis 3, 2
• Tacrolimus 0.1% ointment should be applied once daily to external eyelids and lid margins for 2-4 weeks, showing an 89% response rate in treating eyelid dermatitis 1, 2
• For children aged 2-17 years, start with tacrolimus 0.03% ointment following ophthalmology advice 2
• Identify and eliminate any potential triggers or allergens that may be causing or exacerbating the condition 2

Second-Line Treatment Options

• Topical antihistamine eye drops (such as olopatadine) can be added twice daily if first-line treatment is ineffective or for moderate cases with significant itching 3
• Warm compresses may be beneficial in cases with meibomian gland dysfunction 3, 2
• Lid hygiene measures using specially designed eyelid warming devices or commercially available lid wipes can help clean the eyelid margins 2

Treatment for Moderate-to-Severe Cases

• Referral to ophthalmology is recommended for moderate-to-severe cases not responding to initial treatment 3
• Short-term topical corticosteroids (preservative-free dexamethasone 0.1%) may be prescribed by ophthalmologists for moderate-to-severe cases, but should be limited to a maximum of 8 weeks 3
• Corticosteroid-sparing agents should be started early to facilitate tapering of ocular corticosteroids 3
• Ciclosporin eye drops can be considered for moderate-to-severe cases that don't respond to initial therapy 3, 2

Special Considerations for Children

• Children under 7 years should be referred to ophthalmology due to limited ability to communicate symptoms and risk of interference with normal ocular development 3, 2
• For children 7-17 years with mild-to-moderate perioral dermatitis around the eyes who don't respond to topical lubrication or antihistamine eye drops, refer to ophthalmology through standard referral pathway 3
• For severe cases in children 7-17 years, urgent ophthalmology assessment within 4 weeks is recommended 3

Treatment for Refractory Cases

• Patch testing can be considered for persistent cases to identify specific allergens 3, 2
• Combination therapy with topical corticosteroids, tacrolimus ointment, and ciclosporin drops may be considered for treatment-resistant cases, though evidence is limited 3
• Oral antibiotics (tetracyclines for adults and children >8 years; erythromycin for younger children) may be considered for refractory cases 4, 5

Treatment Pitfalls and Caveats

• Avoid preservative-containing formulations as they can cause additional allergic contact dermatitis 2
• Topical corticosteroids should be avoided or used with extreme caution as they may worsen the condition or cause rebound when discontinued 3, 4
• Prolonged use of topical corticosteroids requires careful consideration of the risk-benefit profile and should warrant joint discussion with ophthalmology 3
• Response to treatment should be assessed after 4 weeks; if no improvement, consider alternative diagnosis or referral to specialist 2

Follow-up Recommendations

• Cases treated with tacrolimus ointment should be arranged for ophthalmology review within 4 weeks 2
• Cases using topical corticosteroids require regular monitoring for signs of skin atrophy, glaucoma, and cataracts 2
• If symptoms persist despite appropriate treatment, consider underlying conditions such as atopic dermatitis or other skin conditions 2