What is the treatment for erythema (redness) around the eyes?

Treatment for Erythema Around Eyes

The first-line treatment for erythema around the eyes includes eyelid hygiene combined with artificial tear substitutes for mild symptoms, with oral doxycycline as the primary pharmacological treatment for cases that don't respond to basic measures. 1

Causes and Diagnosis

• Periorbital erythema can result from multiple conditions including ocular rosacea, medication-induced keratoconjunctivitis, contact dermatitis, atopic dermatitis, and blepharitis 2, 3
• Medication-induced keratoconjunctivitis presents with distinctive signs including contact dermatitis of eyelids with erythema and scaling 2
• Dupilumab, used for atopic dermatitis treatment, is associated with conjunctivitis, keratitis, and blepharitis in 32-55% of patients 2
• Female gender, atopic skin diathesis, and age over 40 are identified risk factors for periocular dermatitis 3

Treatment Algorithm

First-Line Treatments

1. Eyelid Hygiene

   • Recommended as first-line approach for all patients with periorbital erythema, especially for ocular rosacea 1
   • Should be performed daily to reduce inflammation and bacterial load 2, 1

2. Artificial Tear Substitutes

   • Recommended for mild ocular burning/stinging symptoms 1
   • Preservative-free formulations are preferred to avoid further irritation 2

3. Trigger Avoidance

   • Identify and eliminate potential allergens from cosmetics, eye medications, or environmental sources 1, 3
   • Common allergens include fragrances, preservatives, and medications in eye drops 3

Second-Line Treatments

1. Oral Doxycycline

   • First-line pharmacological treatment for cases not responding to basic measures 1
   • Available in standard formulations (≥50 mg with antibiotic activity) or as 40-mg modified-release dose with anti-inflammatory properties 1
   • Treatment should continue for 6-12 weeks before considering it a failure 1
   • Contraindicated in pregnancy, nursing women, children under 8 years, or those with hypersensitivity 1

2. Topical Treatments

   • Topical cyclosporine 0.05% for posterior blepharitis 1
   • Calcineurin inhibitors (tacrolimus, pimecrolimus) for facial atopic eczema and other periocular eczematous lesions 3
   • Brief course of topical corticosteroids for severe eyelid or ocular surface inflammation, which should be tapered once inflammation is controlled 1

For Specific Conditions

1. Rosacea Conjunctivitis

   • Eyelid hygiene, warm compresses, systemic tetracyclines 2
   • Omega-3 fatty acid supplements, topical corticosteroids and cyclosporine 2
   • Topical metronidazole creams and ointment, mechanical thermal pulsations, and intense pulse light therapy 2

2. Contact-Lens-Related Keratoconjunctivitis

   • Discontinue contact lens wear until cornea returns to normal 2
   • Brief (1-2 weeks) course of topical corticosteroids may be prescribed 2
   • Consider longer-term use of topical cyclosporine 0.05% 2

3. Medication-Induced Keratoconjunctivitis

   • Discontinuation of causative medication when possible 2
   • Topical anti-inflammatory treatments for symptom management 2, 1

Special Considerations

• Long-term corticosteroid therapy should be avoided due to risk of glaucoma and cataract 1
• Referral to an ophthalmologist is necessary for ocular rosacea that cannot be controlled with lid hygiene or for greater severity 1
• For contact dermatitis cases, exact identification of relevant contact allergens and allergen elimination are essential for successful treatment 3
• Combination therapy may be required for moderate to severe presentations 1
• Maintenance therapy should use the minimum treatment necessary to maintain control 1

Pitfalls and Caveats

• Avoid long-term use of topical corticosteroids around the eyes due to risk of glaucoma, cataracts, and thinning of periorbital skin 1
• Rebound erythema can occur with continued use of vasoactive medications like oxymetazoline and brimonidine 2
• Ice and water immersion should be avoided or limited to 10 minutes at a time and 4 times daily if used for symptomatic relief 2
• Children with ocular rosacea often present with corneal involvement, asymmetry of ocular disease, and potential for visual impairment 2
• Erythema around eyes may be a manifestation of systemic conditions requiring additional treatment approaches 4, 5