What is the best treatment for contact dermatitis under the eye?

Treatment of Contact Dermatitis Under the Eye

Tacrolimus 0.1% ointment applied once daily to the eyelids and lid margins is the first-line treatment for contact dermatitis around the eye, with an 89% response rate. 1

Initial Management Steps

Identify and eliminate the causative allergen or irritant as this is essential for successful treatment and preventing recurrence. 2, 1 This may require:

• Reviewing all cosmetics, skincare products, eye drops, and contact lens solutions used near the eye 2
• Considering patch testing for persistent cases unresponsive to initial treatment to identify specific allergens 1
• Avoiding preservative-containing formulations as they can cause additional allergic contact dermatitis 1

Apply preservative-free ocular lubricants to soothe the affected area and provide symptomatic relief. 1 This should be initiated immediately as first-line supportive care. 2

Implement lid hygiene measures using specially designed eyelid warming devices or commercially available lid wipes to clean the eyelid margins. 1

Primary Topical Treatment

Start tacrolimus 0.1% ointment applied once daily to external eyelids and lid margins for 2-4 weeks. 1 This is the preferred first-line treatment based on its high efficacy and safety profile for periocular use. 1

• For children aged 2-17 years, start with tacrolimus 0.03% ointment and increase to 0.1% if necessary only following ophthalmology advice (off-license use). 1
• Arrange ophthalmology review within 4 weeks for all patients using tacrolimus ointment on lid margins. 1
• If no response after 2-4 weeks of appropriate use, discontinue tacrolimus and consider alternative treatments. 2

Adjunctive Treatments for Symptomatic Relief

Add topical antihistamine eye drops for mild-to-moderate cases with significant itching. 2, 1 Options include:

• Olopatadine (age >3 years): 2 times daily for up to 4 months 2
• Ketotifen (age >3 years): 2 times daily 2
• Azelastine hydrochloride (age >4 years): 2-4 times daily 2

Apply warm compresses if meibomian gland dysfunction is present. 2, 1

Escalation for Moderate-to-Severe Cases

Refer to ophthalmology for moderate-to-severe cases not responding to initial therapy. 1 Ophthalmology may initiate:

• Short-term ocular topical corticosteroids (preservative-free dexamethasone 0.1%, prednisolone 0.5%, or hydrocortisone 0.335% eye drops) for moderate-to-severe disease 2
• Topical ciclosporin drops as a corticosteroid-sparing agent, potentially started simultaneously with corticosteroids to facilitate tapering 2, 1
• Combination therapy with tacrolimus ointment and ciclosporin drops for treatment-resistant cases 2

Critical Referral Indications

Immediate ophthalmology referral is required for:

• All children under 7 years due to limited ability to communicate symptoms and risk of interference with normal ocular development 1
• Moderate-to-severe cases not responding to initial treatment 1
• Any case requiring topical corticosteroids for monitoring of glaucoma and cataracts 1
• Cases needing corticosteroid therapy for more than 8 weeks 2

Important Caveats and Pitfalls

Avoid topical hydrocortisone cream on eyelids despite FDA approval for general skin use 3, as chronic application can cause severe complications including atrophy, telangiectasia, and rosacea-like eruptions on eyelids. 4 The eyelid skin is particularly vulnerable to corticosteroid-induced complications. 4

Do not use systemic corticosteroids as first-line treatment for periocular contact dermatitis, as this is reserved for extensive body surface area involvement (>20%). 5 The periocular area requires specialized topical management. 1

Consider underlying atopic dermatitis or other skin conditions that may complicate treatment. 1 These patients may have more persistent disease requiring longer-term management strategies.

Beware of corticosteroid contact allergy itself, which can be difficult to diagnose due to the anti-inflammatory properties masking the allergic reaction. 6 This requires specific patch testing with budesonide and tixocortol pivalate with delayed readings. 6

Follow-Up Protocol

Reassess at 4 weeks for patients on tacrolimus ointment during ophthalmology review. 1 If no improvement, consider alternative diagnosis or specialist referral. 1

Monitor regularly if topical corticosteroids are used, checking for signs of skin atrophy, glaucoma, and cataracts. 2, 1