What is the treatment for periorbital pruritus?

Treatment of Periorbital Pruritus

The first-line treatment for periorbital pruritus should be topical calcineurin inhibitors such as tacrolimus 0.03-0.1% or pimecrolimus 1% cream applied twice daily, as they are safe and effective for periorbital dermatitis and associated pruritus. 1

Evaluation and Initial Management

• First determine if periorbital pruritus is related to an underlying dermatosis (like atopic dermatitis, contact dermatitis) or a systemic condition 2
• Common causes of periorbital dermatitis include allergic contact dermatitis (32-44%), atopic eczema (14-25%), airborne contact dermatitis (2-10%), and irritant contact dermatitis (8-9%) 1
• Risk factors include female gender, atopic skin diathesis, and age over 40 years 1
• Consider medication-induced periorbital dermatitis in patients taking new medications (e.g., apixaban has been reported to cause periorbital dermatitis) 3

Treatment Algorithm

First-line treatments:

• Topical calcineurin inhibitors (tacrolimus 0.03-0.1% or pimecrolimus 1% cream) twice daily 1, 4
  • These are particularly effective for facial and periorbital areas where skin is thin 1
  • Apply a thin layer to affected areas, avoiding contact with eyes 5
  • Continue until signs and symptoms resolve 5

Second-line treatments:

• Non-sedating antihistamines (fexofenadine or loratadine) for pruritus relief 2
• Emollients to maintain skin hydration and repair barrier function 2, 6
• Topical menthol preparations for temporary relief of pruritus 2

For refractory cases:

• Consider short-term, low-potency topical corticosteroids (use cautiously in periorbital area due to risk of glaucoma, cataracts, and skin atrophy) 6, 7
• Investigate for underlying systemic causes if pruritus persists despite appropriate topical therapy 8, 2

Management of Underlying Systemic Causes

If hematological disorders are suspected:

• Order full blood count, blood film, lactate dehydrogenase and ESR 8
• For polycythemia vera-associated pruritus:
  • Aspirin 300 mg daily can be effective 8
  • Consider cytoreductive therapy, interferon-α, SSRIs, PUVA, UVB phototherapy, cimetidine or atenolol if aspirin is ineffective 8

If lymphoma is suspected:

• Consider cimetidine, gabapentin, carbamazepine, mirtazapine or phototherapy 8
• For incurable lymphoma, oral corticosteroids may provide relief 8

For solid tumor-associated pruritus:

• Consider paroxetine, mirtazapine, granisetron, or aprepitant 8, 2

For hepatic pruritus:

• First-line: rifampicin 8, 2
• Second-line: cholestyramine 8, 2
• Avoid gabapentin in hepatic pruritus 8, 2

For uremic pruritus:

• Optimize dialysis parameters, normalize calcium-phosphate balance 8, 2
• BB-UVB phototherapy is effective 8, 2

Important Considerations and Pitfalls

• Avoid long-term use of sedative antihistamines except in palliative care settings due to potential dementia risk 8, 2
• For periorbital application, ensure medications do not enter the eyes; if they do, rinse with cold water 5
• Limit sun exposure during treatment with calcineurin inhibitors and avoid UV light therapy 5
• If symptoms do not improve after 6 weeks of treatment, reevaluate diagnosis as other skin diseases can mimic eczema 5
• Discontinue suspected causative medications if possible and consider alternatives 3

Follow-up

• Monitor response to treatment within 1-2 weeks 4
• If no improvement occurs, consider skin biopsy to rule out rare conditions like cutaneous lymphoma 8
• For persistent, unexplained pruritus, perform systematic evaluation for underlying systemic diseases 7