What is the treatment for periorbital dermatitis?

Treatment of Periorbital Dermatitis

First-line treatment for periorbital dermatitis should be preservative-free ocular lubricants, such as hyaluronate drops, applied 2-4 times daily, with tacrolimus 0.1% ointment applied once daily to external eyelids and lid margins for 2-4 weeks for cases not responding to lubricants alone. 1

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 2, 1
• Formulations with higher hyaluronate percentage offer greater therapeutic efficacy and should be used in more severe disease 2
• Tacrolimus 0.1% ointment applied once daily to external eyelids and lid margins for 2-4 weeks shows an 89% response rate in treating eyelid dermatitis 2, 1, 3
• For children aged 2-17 years, start with tacrolimus 0.03% ointment following ophthalmology consultation 1
• Avoid preservative-containing formulations as they can cause additional allergic contact dermatitis 1

Second-Line Treatment Options

• Add topical antihistamine eye drops (e.g., olopatadine) twice daily if first-line treatment is ineffective or for moderate cases with significant itching 2, 1
• Antihistamine eyedrops show a lower response rate (42%) compared to tacrolimus (89%) but can be beneficial for itching symptoms 2
• Warm compresses may be beneficial in cases with meibomian gland dysfunction 1
• Lid hygiene measures show approximately 50% response rate and should be considered as supportive care 2

Treatment for Moderate-to-Severe Cases

• Refer to ophthalmology for moderate-to-severe cases not responding to initial treatment within 4 weeks 2, 1
• Short-term topical corticosteroids (preservative-free dexamethasone 0.1%, prednisolone 0.5%, or hydrocortisone 0.335% eyedrops) may be prescribed by ophthalmologists for moderate-to-severe cases 2, 1
• Limit corticosteroid use to a maximum of 8 weeks due to risk of skin atrophy, glaucoma, and cataracts 1
• Consider early introduction of corticosteroid-sparing agents (e.g., ciclosporin drops) in people with moderate-to-severe disease 2

Special Considerations for Children

• Children under 7 years should be referred to ophthalmology before initiating treatment due to limited ability to communicate symptoms and risk of interference with normal ocular development 2, 1
• Antihistamine eyedrops are unlikely to be beneficial for children aged < 7 years with periorbital dermatitis 2
• Lubricants should only be recommended for children aged < 7 years following discussion with ophthalmology 2

Treatment for Refractory Cases

• Patch testing should be considered for persistent cases to identify specific allergens, particularly when allergic contact dermatitis is suspected 2, 1, 4
• Combination therapy with tacrolimus ointment and ciclosporin drops may be considered for treatment-resistant cases 2, 1
• Consider medication-induced periorbital dermatitis in refractory cases and review all current medications 5, 6
• Ciclosporin eyedrops show a 63% response rate and can be considered for cases not responding to other treatments 2

Treatment Pitfalls and Caveats

• Topical corticosteroids should be avoided or used with extreme caution as they may worsen the condition or cause rebound when discontinued 1, 7
• In a study of refractory periorbital dermatitis, over 80% of patients using topical hydrocortisone experienced persistent irritation and erythema 6
• Calcineurin inhibitors (tacrolimus, pimecrolimus) are preferred over corticosteroids for facial dermatitis due to lower risk of adverse effects 4, 7
• Allergic contact dermatitis is a common cause of periorbital dermatitis (32-44% of cases), so allergen identification and elimination are essential for successful treatment 4

Follow-up Recommendations

• Assess response to lubricant therapy at 4 weeks; if ineffective, escalate treatment 2
• Cases treated with tacrolimus ointment should have ophthalmology review within 4 weeks 1
• Cases using topical corticosteroids require regular monitoring for adverse effects 1
• If no improvement after 4 weeks of treatment with antihistamine eyedrops, refer for routine ophthalmology assessment 2