What are the treatment options for dry skin under the eyes caused by eczema?

Treatment of Dry Skin Under the Eyes Caused by Eczema

For periocular eczema, start with hypoallergenic emollients applied at least once daily, combined with low-potency topical corticosteroids like hydrocortisone 1% cream for short-term use, and consider tacrolimus 0.1% ointment applied to the eyelids and lid margins for maintenance therapy, especially in cases requiring steroid-sparing treatment. 1

First-Line Management: Emollients and Barrier Protection

• Apply hypoallergenic moisturizing creams or ointments at least once daily to the periocular area to restore the skin's lipid barrier and prevent moisture loss 1
• Emollients containing urea and glycerol are particularly effective for eczematous skin, showing superior barrier strengthening compared to simple paraffin-based products 2, 3
• Use preservative-free formulations when possible, as the periocular area has increased susceptibility to allergic contact dermatitis 1
• Avoid greasy occlusive creams around the eyes as they may worsen folliculitis 1

Avoidance of Aggravating Factors

• Use gentle, pH-neutral cleansers instead of soaps and detergents, which strip natural lipids from already compromised skin 1
• Avoid hot water when cleansing the face; use tepid water and pat (don't rub) the skin dry 1
• Eliminate exposure to irritants including harsh facial products, fragrances, and alcohol-containing lotions 1

Anti-Inflammatory Treatment

Topical Corticosteroids

• Hydrocortisone 1% cream is the safest initial choice for periocular eczema due to the thin, sensitive skin in this area 1
• Apply once daily (not twice daily) as evidence shows equal efficacy with reduced side effects 4
• Use the least potent preparation needed to control symptoms, with short treatment breaks when possible to minimize risks of perioral dermatitis and skin atrophy 1
• For moderate-to-severe cases, prednicarbate cream 0.02% may be used under dermatologic supervision 1

Topical Calcineurin Inhibitors (Steroid-Sparing Option)

• Tacrolimus 0.1% ointment applied once daily to external eyelids and lid margins is highly effective for periocular eczema, with 89% response rates reported 1
• This is an off-label use but represents best practice for maintenance therapy in this sensitive area 1
• Arrange ophthalmology review within 4 weeks when initiating tacrolimus around the eyes 1
• Contraindicated in patients with history of ocular herpes simplex or varicella zoster infection 1
• Pimecrolimus has also been reported effective, though one randomized trial showed it ineffective for drug-induced rash 1

Adjunctive Measures for Symptomatic Relief

• For pruritus, use urea- or polidocanol-containing lotions to soothe itching 1
• Oral antihistamines have limited evidence for eczema treatment and should not be routinely used 4
• Keep nails short to minimize trauma from scratching 1

When to Refer to Ophthalmology

• Immediate referral if visual symptoms develop, including blurred vision, eye pain, or photophobia 1
• Refer within 2-4 weeks if symptoms persist despite initial treatment with emollients and low-potency topical steroids 1
• All children under 7 years with periocular eczema should be evaluated by ophthalmology due to risk of interference with normal ocular development 1

Common Pitfalls to Avoid

• Do not use topical acne medications (retinoids, benzoyl peroxide) near the eyes as they cause excessive dryness and irritation 1
• Avoid manipulation or rubbing of the affected skin, which increases infection risk 1
• Do not use topical or oral antibiotics routinely unless secondary bacterial infection is confirmed, as evidence does not support their use for uncomplicated eczema 4
• Emollient bath additives have not been shown to benefit eczema and resources are better spent on leave-on emollients 4

Treatment Algorithm Summary

1. Start with barrier repair: Hypoallergenic emollient (preferably urea-glycerol containing) at least once daily 1, 2
2. Add anti-inflammatory: Hydrocortisone 1% cream once daily for active inflammation 1
3. Transition to maintenance: Tacrolimus 0.1% ointment for steroid-sparing long-term control 1
4. Refer if no improvement in 2-4 weeks or if any ocular symptoms develop 1