What is the best treatment for psoriasis on the eyelids?

Treatment of Psoriasis on the Eyelids

For psoriasis on the eyelids, use low-potency topical corticosteroids (such as 1% hydrocortisone) or calcipotriene combined with hydrocortisone for 8 weeks, avoiding high-potency corticosteroids due to the high risk of skin atrophy and telangiectasia in this vulnerable area. 1, 2

Why the Eyelids Require Special Treatment Considerations

• The eyelid skin is among the thinnest and most vulnerable areas of the body, making it highly susceptible to corticosteroid-induced complications including atrophy, telangiectasia, and periocular dermatitis 3
• Even 1% hydrocortisone (a low-potency agent) can cause severe atrophy and telangiectasia of the eyelids with chronic, uninterrupted application 3
• The American Academy of Dermatology specifically recommends low-potency corticosteroids for facial and intertriginous psoriasis to avoid skin atrophy 2, 4

First-Line Treatment Approach

• Apply calcipotriene combined with hydrocortisone for 8 weeks as the preferred initial therapy, which provides efficacy while minimizing corticosteroid exposure 1
• An 8-week RCT demonstrated that treatments containing hydrocortisone were more effective on the face compared to calcipotriene alone (odds ratio 2.01, P = 0.001) 1
• Alternatively, use 1% hydrocortisone cream intermittently (not continuously) if combination therapy is unavailable 3

Critical Safety Measures for Eyelid Treatment

• Never use high-potency (class 1-3) or ultrahigh-potency corticosteroids on the eyelids, as this dramatically increases the risk of irreversible atrophy and telangiectasia 2, 4, 3
• Limit continuous corticosteroid application to short courses; switch to intermittent therapy (every-other-day or weekend-only) once initial control is achieved 5, 6
• Two female adults developed severe atrophy and telangiectasia of the eyelids following long-term application of even 1% hydrocortisone cream, emphasizing that no topical corticosteroid is completely safe with chronic use on eyelids 3

Alternative and Adjunctive Options

• Tacrolimus (topical calcineurin inhibitor) is an excellent corticosteroid-sparing option for eyelid psoriasis, as it does not cause skin atrophy and is specifically recommended as first-line for intertriginous and facial psoriasis 4, 5
• Calcitriol ointment (vitamin D analogue) can be used for facial areas to avoid corticosteroid-related atrophy 2
• The warm, moist environment of periocular areas increases medication penetration, which paradoxically increases both efficacy and risk of adverse effects 4

Treatment Duration and Monitoring

• Limit initial treatment with low-potency corticosteroids to 4 weeks maximum for continuous use 4
• After achieving initial control, transition to maintenance with intermittent application (weekend-only corticosteroid with weekday vitamin D analogue) 4, 5
• Regular clinical examination is essential to detect early signs of atrophy, telangiectasia, or periocular dermatitis 3, 6

Common Pitfalls to Avoid

• Do not prescribe unsupervised repeat prescriptions of any topical corticosteroid for eyelid use without regular clinical review 2
• Avoid the temptation to use more potent corticosteroids for faster results—the eyelid complications can be severe and potentially irreversible 3
• Do not apply vitamin D analogues simultaneously with salicylic acid, as the acidic pH inactivates the vitamin D compound 4
• Therapy with any effective topical corticosteroid should be intermittent, with particular care in vulnerable areas like the eyelids 3