What is the recommended treatment for eyelid eczema?

Treatment of Eyelid Eczema

Start with low-to-moderate potency topical corticosteroids applied twice daily maximum to affected eyelid skin, combined with liberal emollient use, as this remains the mainstay of treatment even for this delicate periocular area. 1, 2

First-Line Treatment Strategy

• Apply low-to-moderate potency topical corticosteroids (such as hydrocortisone 1%) to the eyelid skin twice daily maximum, using the least potent preparation that achieves control 1, 2
• Never use very potent or potent corticosteroids around the eyes due to the extremely high risk of skin atrophy, given the thin skin in this area 2
• Implement short "steroid holidays" when the eczema is controlled to minimize side effects including pituitary-adrenal suppression 1, 2
• In children, exercise particular caution with topical corticosteroids due to increased risk of systemic absorption and potential growth interference 2

Essential Emollient Therapy

• Apply emollients liberally and regularly to the periocular area, even when eczema appears controlled, as this restores the skin barrier and is the cornerstone of maintenance therapy 1, 2
• Apply emollients after bathing to provide a surface lipid film that prevents evaporative water loss 1, 2
• Use soap-free cleansers and avoid alcohol-containing products near the eyes 2

Managing Secondary Infections

Do not delay or withhold topical corticosteroids when infection is present - they remain the primary treatment when appropriate systemic antibiotics are given concurrently 1, 2

• 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, 2
• If you observe grouped vesicles, punched-out erosions, or sudden deterioration with fever, suspect eczema herpeticum - this is a medical emergency 1, 2
• Initiate oral acyclovir immediately and early in the disease course 1, 2
• In ill, feverish patients, administer acyclovir intravenously 1

Second-Line Treatment for Refractory Cases

When topical corticosteroids fail to control eyelid eczema after 4 weeks, escalate to calcineurin inhibitors:

• Apply tacrolimus 0.03% ointment to affected eyelid skin twice daily for severe atopic eyelid disease refractory to topical corticosteroids 2
• Tacrolimus 0.1% ointment applied once daily to the external eyelids and lid margins can be used as an off-license treatment in appropriate cases, typically after ophthalmology consultation 3, 2
• Tacrolimus ointment shows an 89% response rate in observational series, making it highly effective for eyelid eczema 3
• Do not use tacrolimus in patients with a history of ocular-surface herpes simplex virus or varicella zoster virus 3
• In children aged 2-17 years, tacrolimus should only be used following advice from ophthalmology, starting with 0.03% ointment 3

Additional Treatment Options

For patients with concurrent ocular surface involvement or dry eye symptoms:

• Preservative-free hyaluronate eyedrops applied 2-4 times daily can be beneficial, with higher hyaluronate percentages offering greater therapeutic efficacy 3
• Olopatadine antihistamine eyedrops twice daily may be trialed in addition to lubricants if lubricants alone are ineffective 3
• Ciclosporin eyedrops for severe keratitis should typically be initiated by ophthalmology 3

Identifying and Managing Contact Allergens

Allergic contact dermatitis is the most common cause of eyelid dermatitis, found in 74% of cases in one large series 4

• The most common contact allergens are metals, fragrances, preservatives, acrylates, and topical medications found in cosmetics, ophthalmic medications, nail lacquers, and jewelry 5, 4
• Consider patch testing in patients with persistent eyelid eczema despite optimized topical therapy, as allergen avoidance can lead to significant improvement 3, 4
• Important sources include cosmetics, eye medications, artificial nails, dust mites, and animal dander - only 5% of cases are caused by nail lacquer alone 4

Critical Pitfalls to Avoid

• Never use potent or very potent corticosteroids around the eyes - the risk of skin atrophy and ocular complications is unacceptably high 2
• Do not use continuous corticosteroids without breaks - implement treatment holidays when disease is controlled 1, 2
• Patients' or parents' fears of steroids often lead to undertreatment - explain the different potencies and the benefits/risks clearly 1
• Non-sedating antihistamines have little to no value in atopic eczema and should not be used 1

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 2
• Refer moderate-to-severe disease requiring topical corticosteroids for more than 8 weeks 2
• Refer treatment-resistant disease despite optimized topical therapy 2
• Refer immediately if eczema herpeticum is suspected 2
• Arrange ophthalmology review within 4 weeks for cases treated with tacrolimus ointment to lid margins 3