What is the recommended treatment for eczema of the eyelid?

Treatment for Eyelid Eczema

Start with preservative-free emollients applied at least once daily combined with hydrocortisone 1% cream applied twice daily to the eyelids as first-line therapy, and if inadequate response occurs after 2-4 weeks, escalate to tacrolimus 0.1% ointment applied once daily to the external eyelids and lid margins. 1

First-Line Treatment Approach

Emollients and Barrier Restoration

• Apply preservative-free hypoallergenic moisturizing creams or ointments at least once daily to restore the skin's lipid barrier around the eyes 1
• Use emollients after bathing when they are most effective at retarding evaporative water loss 2
• Avoid soaps and detergents; instead use a dispersible cream as a soap substitute to cleanse the periocular area 2

Initial Topical Corticosteroid

• Hydrocortisone 1% cream is the safest and recommended initial topical corticosteroid for eyelid eczema due to the thin, delicate periocular skin 1
• Apply twice daily during active flare-ups 1
• Use the least potent preparation required to control the eczema, with intermittent application rather than continuous use 2

Critical caveat: While hydrocortisone 1% is generally safe, chronic uninterrupted application can cause atrophy and telangiectasia of the eyelids, even with this mild-potency steroid 3. Therefore, treatment should be intermittent with short breaks once control is achieved 2, 3.

Second-Line Treatment: Tacrolimus Ointment

When to Escalate

• If hydrocortisone 1% is ineffective after 2-4 weeks of appropriate use 1
• For maintenance therapy to avoid prolonged topical corticosteroid use 1
• In patients requiring corticosteroid-sparing agents 2

Tacrolimus Application Protocol

• Apply tacrolimus 0.1% ointment once daily to external eyelids and lid margins 2, 1
• The ointment can be applied directly to the ocular surface of the lids (off-license use) for best effect, though this is typically initiated by ophthalmology 2
• Trial for 2-4 weeks before determining effectiveness 2, 1
• Tacrolimus demonstrates an 89% response rate for periocular eczema 1 and is probably more effective than hydrocortisone 1% in moderate-to-severe cases 4, 5

Important safety considerations:

• Do not use tacrolimus in patients with a history of ocular-surface herpes simplex virus or varicella zoster virus 2
• The most common side effect is transient burning or warmth at the application site, typically occurring during the first 5 days and resolving within a few days 6, 4
• Tacrolimus does not cause the skin atrophy or increased intraocular pressure associated with topical corticosteroids 4, 5

Pediatric Considerations

• For children aged 2-17 years, tacrolimus should only be used following advice from ophthalmology 2
• Consider starting with tacrolimus 0.03% ointment in children, though tacrolimus 0.1% is acceptable as off-license treatment in appropriate cases 2
• Do not use tacrolimus or pimecrolimus in children under 2 years of age 6

Adjunctive Symptomatic Measures

• Use urea- or polidocanol-containing lotions to soothe itching 1
• Sedating antihistamines may help with severe pruritus during flares, though their value lies primarily in sedative properties rather than direct anti-itch effects 2, 1
• Keep nails short to minimize trauma from scratching 2
• Avoid extremes of temperature and irritant exposure 2

When to Refer to Ophthalmology

Urgent Referral Indications

• Any child under 7 years with periocular eczema should have early ophthalmology discussion within 7 days before treatment is commenced 1
• Visual symptoms develop, including blurred vision, eye pain, or photophobia 1
• Grouped, punched-out erosions or vesicles suggesting eczema herpeticum 2, 1

Non-Urgent Referral Indications

• Severe periocular eczema in any patient 1
• Symptoms persist despite 2-4 weeks of emollients and hydrocortisone 1% cream 1
• Moderate-to-severe disease in adults or children over 7 years 1
• Need for ophthalmology-initiated treatments such as preservative-free dexamethasone 0.1% eyedrops or ciclosporin eyedrops 1

Treatment Algorithm for Escalation

Step 1 (Mild disease): Preservative-free emollients + hydrocortisone 1% cream twice daily 1

Step 2 (Inadequate response after 2-4 weeks): Add tacrolimus 0.1% ointment once daily to lid margins 2, 1

Step 3 (Still inadequate): Refer to ophthalmology for consideration of preservative-free dexamethasone 0.1% eyedrops, ciclosporin eyedrops, or ocular lubricants 1

Critical Pitfalls to Avoid

• Never use potent or very potent topical corticosteroids on eyelid skin without ophthalmology supervision 2, 1 - the risk of skin atrophy, telangiectasia, and glaucoma is significantly elevated in this delicate area
• Avoid continuous, uninterrupted application of any topical corticosteroid to the eyelids 2, 3 - even hydrocortisone 1% can cause atrophy and telangiectasia with chronic use
• Do not apply tacrolimus or pimecrolimus to the eyes themselves 6 - if accidental contact occurs, rinse with cold water
• Never use topical acne medications near the eyes 1 - they cause excessive dryness and irritation
• Do not ignore signs of secondary infection 2 - crusting or weeping suggests bacterial infection requiring flucloxacillin; grouped vesicles suggest herpes simplex requiring oral acyclovir

Special Consideration: Eczema Herpeticum

• If the patient develops grouped, punched-out erosions or vesicles with fever and deterioration of previously stable eczema, this suggests eczema herpeticum 2, 1
• This requires immediate treatment with oral acyclovir given early in the disease course 2
• In ill, feverish patients, acyclovir should be given intravenously 2