Can topical corticosteroids (steroids) be used to treat redness and puffiness under the eye?

Topical Corticosteroids for Periorbital Redness and Puffiness

Topical corticosteroids should NOT be used for routine treatment of redness and puffiness under the eyes, as this is not an approved indication and carries significant risks of skin atrophy, telangiectasia, and steroid-induced dermatitis in this delicate periorbital area. 1, 2

Why Steroids Are Inappropriate for This Indication

Lack of Approved Use

• Topical corticosteroids are indicated for specific ocular conditions (severe allergic conjunctivitis, adenoviral keratoconjunctivitis with marked inflammation, blepharitis), not for cosmetic periorbital concerns like puffiness or redness 3
• The periorbital skin is among the thinnest and most sensitive on the body, making it particularly vulnerable to steroid-induced adverse effects 1, 4

Significant Risk of Steroid-Induced Dermatitis

• Facial application of topical steroids, especially around the eyes, commonly leads to steroid dermatitis resembling rosacea, characterized by facial redness, telangiectasia, rebound phenomenon, and papulopustular eruptions 1
• Young women are particularly susceptible, with misuse often occurring for pigmentary problems through non-medical recommendations 1
• Once steroid addiction develops, the only effective treatment is absolute total cessation of all corticosteroid use, which itself causes a distinctive pattern of flaring erythema that can last weeks to months 2

Specific Ocular Risks When Used Periocularly

• Even when used appropriately for ocular conditions, topical corticosteroids require monitoring for elevated intraocular pressure, glaucoma, and cataract formation 3
• Corticosteroids with poor ocular penetration (fluorometholone, loteprednol) are preferred when ocular use is necessary to minimize these risks 3

When Periocular Steroids ARE Appropriate

Severe Allergic Conjunctivitis

• A brief 1-2 week course of low side-effect profile topical corticosteroids (such as loteprednol etabonate) may be added only when symptoms are inadequately controlled with first-line dual-action antihistamine/mast cell stabilizers 3, 5
• Requires baseline and periodic intraocular pressure measurement plus pupillary dilation to evaluate for glaucoma and cataract 3, 5

Severe Adenoviral Keratoconjunctivitis

• Topical corticosteroids are helpful to reduce symptoms and may reduce scarring in severe cases with marked chemosis, eyelid swelling, epithelial sloughing, or membranous conjunctivitis 3
• Close follow-up is mandatory, as animal studies show prolonged viral shedding with steroid use 3

Blepharitis with Severe Inflammation

• A brief course may help with eyelid or ocular surface inflammation, including marginal keratitis or phlyctenules 3
• Must use minimal effective dose and taper once inflammation is controlled 3

Critical Pitfalls to Avoid

• Never use topical steroids on facial skin for cosmetic concerns (redness, puffiness, pigmentation) as this leads to steroid addiction and rebound dermatitis 1, 2
• Never use topical steroids in herpes simplex virus infections without antiviral coverage, as they potentiate HSV epithelial infections 3, 6
• Avoid long-term use due to risks of skin atrophy, telangiectasia, increased intraocular pressure, and cataract formation 3, 4
• Do not use potent or very potent steroids on the face under any circumstances 1

Appropriate Alternatives for Periorbital Concerns

For Allergic Symptoms

• Cold compresses and refrigerated preservative-free artificial tears as first-line symptomatic treatment 3, 5
• Dual-action topical antihistamine/mast cell stabilizers (olopatadine, ketotifen, epinastine, azelastine) for allergic etiology 3, 5
• Allergen avoidance strategies including sunglasses as a barrier 3, 5

For Non-Allergic Redness or Puffiness

• Identify and treat underlying cause (contact dermatitis, blepharitis, systemic conditions)
• Consider referral to dermatology or ophthalmology for proper evaluation rather than empiric steroid use 1