Treatment for Eczema Around the Eyes
Start with topical corticosteroids as first-line therapy, using the lowest potency that controls symptoms, applied no more than twice daily to the periocular area, with special caution given the thin skin around the eyes. 1, 2
First-Line Treatment Approach
Topical Corticosteroids
- Apply low-to-moderate potency topical corticosteroids (such as hydrocortisone) to affected eyelid skin twice daily maximum. 1, 2, 3
- Avoid very potent or potent corticosteroids around the eyes due to the high risk of skin atrophy in this thin-skinned area. 1
- Use the least potent preparation that achieves control, and implement short "steroid holidays" when possible to minimize side effects including pituitary-adrenal suppression. 1, 2
- In children, use topical corticosteroids with particular caution due to increased risk of systemic absorption and growth interference. 1, 4
Essential Adjunctive Measures
- Apply emollients liberally and regularly to the periocular area, even when eczema appears controlled, to restore the skin barrier. 2, 5
- Use soap-free cleansers and avoid alcohol-containing products near the eyes. 2
- Apply emollients after bathing to provide a surface lipid film that prevents water loss. 1, 2
Managing Secondary Infections
- Watch for signs of bacterial superinfection: increased crusting, weeping, or pustules around the eyes. 2
- Prescribe oral flucloxacillin for suspected Staphylococcus aureus infection, the most common pathogen. 1, 4, 2
- Continue topical corticosteroids during bacterial infection when appropriate systemic antibiotics are given concurrently. 2
- If you observe grouped vesicles, punched-out erosions, or sudden deterioration—suspect eczema herpeticum and initiate oral acyclovir immediately; this is a medical emergency. 1, 4, 2
Second-Line Treatment for Refractory Cases
Topical Calcineurin Inhibitors
- For severe atopic eyelid disease refractory to topical corticosteroids, initiate tacrolimus 0.03% ointment applied to affected eyelid skin twice daily. 1, 6
- Tacrolimus can be increased to 0.1% potency as an off-license treatment in appropriate cases after ophthalmology consultation. 1
- Tacrolimus has demonstrated substantial improvement in eyelid induration, erythema, and eczematous changes within 1-3 weeks, with safe use documented for up to 14 months. 6
- This approach allows discontinuation of long-standing topical corticosteroid use and avoids steroid-related complications. 6
Topical Ciclosporin Eyedrops
- Consider ciclosporin eyedrops for patients with concurrent ocular surface involvement, though this should typically be initiated by ophthalmology. 1
Lid Hygiene Measures (Adults Only)
- For patients with blepharitis or lid margin disease, recommend warm compresses using specially designed battery-powered or microwaveable devices (not hot water-soaked flannels due to scalding risk), followed by eyelid massage and cleaning with bicarbonate solution or commercial lid wipes. 1
- Do not recommend this approach in children, as they are unlikely to adhere to the regimen and the etiology differs. 1
Critical Pitfalls to Avoid
- Never delay topical corticosteroids when infection is present—they remain primary treatment when appropriate systemic antibiotics are given. 2
- Do not use potent or very potent corticosteroids around the eyes due to high risk of skin atrophy and ocular complications. 1
- Avoid continuous corticosteroid use without breaks—implement treatment holidays when disease is controlled. 1, 2
- Do not use non-sedating antihistamines, as they have no value in treating eczema. 4, 2
When to Refer to Ophthalmology
- Refer any child under 7 years with periocular eczema to ophthalmology due to limited ability to communicate symptoms and risk of interference with normal ocular development. 1
- Refer moderate-to-severe disease requiring topical corticosteroids for more than 8 weeks. 1
- Refer treatment-resistant disease despite optimized topical therapy. 1
- Refer immediately if eczema herpeticum is suspected. 1, 2