How to treat psoriasis on the eyelid?

Treatment of Eyelid Psoriasis

For psoriasis on the eyelid, use low-potency topical corticosteroids (such as hydrocortisone) combined with calcipotriene for initial treatment, with careful monitoring for complications, or consider tacrolimus ointment 0.03-0.1% as a steroid-sparing alternative for this sensitive periocular area. 1

First-Line Treatment Approach

Low-Potency Topical Corticosteroids

• Hydrocortisone 1% is the safest corticosteroid option for eyelid application, though even this low-potency agent requires intermittent use to avoid complications 2
• Apply once daily for 2-4 weeks maximum during acute flares 1
• Critical warning: Chronic, uninterrupted application of even 1% hydrocortisone on eyelids can cause atrophy, telangiectasia, rosacea-like eruptions, and perioral dermatitis 2
• Avoid mid-to-high potency corticosteroids (Class I-III) on eyelids due to high risk of skin atrophy and other complications 1

Vitamin D Analogues for Facial/Eyelid Psoriasis

• Calcipotriene combined with low-potency corticosteroid (hydrocortisone) for 8 weeks is specifically recommended for facial psoriasis and can be applied to eyelid skin 1
• This combination is more effective than either agent alone while reducing corticosteroid exposure 1
• Apply calcipotriene in the evening and corticosteroid in the morning, or use a combination product 1

Steroid-Sparing Alternative: Tacrolimus

Tacrolimus Ointment (Off-Label for Psoriasis)

• Tacrolimus 0.03% or 0.1% ointment is an excellent steroid-sparing option for eyelid psoriasis, particularly for chronic management 1
• For adults: Use tacrolimus 0.1% ointment once daily to external eyelids and lid margins 1
• For children ages 2-15 years: Use tacrolimus 0.03% ointment; 0.1% may be used in those 16+ years 1
• Can be applied directly to the ocular surface of lids for best effect, though this is off-label and ideally initiated by ophthalmology 1
• Provides 89% response rate in managing periocular inflammatory conditions 1
• Contraindication: Do not use in patients with history of ocular herpes simplex virus or varicella zoster virus 1

Treatment Algorithm

Week 1-4 (Acute Phase):

• Start with hydrocortisone 1% ointment once daily to eyelid skin 2
• Add calcipotriene ointment in evening if tolerated 1
• Use emollients/moisturizers liberally to reduce scaling 1

Week 4-8 (Transition Phase):

• Taper corticosteroid to every-other-day or weekend-only application 1, 3
• Continue calcipotriene daily 1
• Consider switching to tacrolimus 0.1% ointment if corticosteroid complications develop or for long-term maintenance 1

Maintenance (Beyond 8 Weeks):

• Use tacrolimus 0.1% ointment as primary maintenance therapy to avoid long-term corticosteroid complications 1
• Reserve low-potency corticosteroids for intermittent flares only 1, 3, 2
• Continue emollients indefinitely 1

Critical Monitoring and Precautions

Ophthalmology Referral Indications

• Arrange ophthalmology review within 4 weeks when using tacrolimus on eyelids 1
• Refer immediately if patient develops eye pain, vision changes, or signs of corneal involvement 1
• Baseline and periodic IOP measurement if using any corticosteroids periocularly 1

Common Pitfalls to Avoid

• Never use potent or superpotent corticosteroids on eyelids - the thin skin dramatically increases absorption and complication risk 1, 2
• Avoid continuous daily corticosteroid application - even low-potency agents cause complications with chronic use 2
• Do not combine salicylic acid with calcipotriene as the acidic pH inactivates calcipotriene 1
• Avoid anthralin and coal tar on eyelids due to severe irritation risk 1

Patient Counseling Points

• Explain that psoriasis is chronic and requires long-term management with intermittent therapy 1, 3
• Warn about potential for skin atrophy and telangiectasia with prolonged corticosteroid use on eyelids 2
• Tacrolimus may cause initial burning sensation that typically improves with continued use 1
• Emphasize importance of emollient use to maintain skin barrier 1