How to treat psoriasis on the eyelid?

Treatment of Eyelid Psoriasis

Start with hydrocortisone 1% ointment once daily to the eyelid skin for 2-4 weeks maximum, combined with calcipotriene ointment in the evening if tolerated, then transition to tacrolimus 0.1% ointment for long-term steroid-sparing maintenance. 1

First-Line Treatment: Low-Potency Corticosteroids

• Apply hydrocortisone 1% ointment (the only appropriate corticosteroid for eyelids) once daily during acute flares for a maximum of 2-4 weeks 1
• Add calcipotriene ointment in the evening if the patient tolerates it without irritation 1
• Use emollients and moisturizers liberally throughout the day to reduce scaling and maintain the skin barrier 1
• Never use mid-to-high potency corticosteroids on eyelids due to extremely high risk of skin atrophy, telangiectasia, and other serious complications 1, 2

Critical Monitoring During Corticosteroid Use

• Arrange baseline and periodic intraocular pressure (IOP) measurements when using any corticosteroids periocularly 1
• Refer immediately to ophthalmology if the patient develops eye pain, vision changes, or signs of corneal involvement 1
• Even hydrocortisone 1% can cause eyelid atrophy and telangiectasia with chronic uninterrupted use, so intermittent therapy is essential 2

Transition to Steroid-Sparing Maintenance: Tacrolimus

• After 4 weeks of corticosteroid therapy, taper to every-other-day or weekend-only application, then transition to tacrolimus for chronic management 1
• Use tacrolimus 0.1% ointment once daily to external eyelids and lid margins for adults (tacrolimus 0.03% for children ages 2-15 years) 1
• Tacrolimus demonstrates an 89% response rate in managing periocular inflammatory conditions and serves as an excellent long-term option 1
• Arrange ophthalmology review within 4 weeks when initiating tacrolimus on eyelids 1

Patient Counseling for Tacrolimus

• Warn patients that tacrolimus may cause initial burning sensation that typically improves with continued use 1
• Explain that psoriasis is chronic and requires long-term management with intermittent therapy rather than continuous daily treatment 1

Agents to Absolutely Avoid on Eyelids

• Never use anthralin or coal tar on eyelids due to severe irritation risk 1
• Do not combine salicylic acid with calcipotriene, as the acidic pH inactivates calcipotriene 1, 3
• Avoid potent or superpotent corticosteroids (anything stronger than hydrocortisone) on eyelid skin 1

Common Pitfalls

• Avoid continuous daily corticosteroid application, even with low-potency agents like hydrocortisone—intermittent therapy is mandatory 1
• Do not abruptly stop corticosteroids after prolonged use; taper frequency gradually to prevent rebound flare 4
• Recognize that eyelid skin is particularly vulnerable to corticosteroid-induced atrophy and telangiectasia, requiring extra caution 2

When to Refer to Ophthalmology

• Refer within 4 weeks when using tacrolimus on eyelids for baseline assessment 1
• Refer immediately (within 24 hours) if severe symptoms develop, including eye pain, vision changes, or corneal involvement 1
• Refer for routine assessment if mild-to-moderate disease does not respond to topical treatment and lid hygiene 5