What is the best treatment for eczema around the nose and eyelid?

Treatment of Eczema Around the Nose and Eyelid

Apply a low-to-moderate potency topical corticosteroid (such as hydrocortisone 1% or desonide 0.05%) twice daily maximum to the affected periocular and nasal skin, combined with liberal preservative-free emollient use, as this represents first-line therapy for this anatomically sensitive area. 1

First-Line Treatment: Topical Corticosteroids with Critical Safety Precautions

The periocular and nasal areas require special consideration due to the exceptionally thin skin in these locations, which dramatically increases the risk of corticosteroid-induced skin atrophy and systemic absorption. 1, 2

Specific corticosteroid selection and application:

• Use only low-to-moderate potency preparations (hydrocortisone 1%, desonide 0.05%, or similar) around the eyes and nose—never potent or very potent corticosteroids in these areas. 1
• Apply no more than twice daily; once-daily application is equally effective if adherence is a concern (OR 0.97,95% CI 0.68 to 1.38). 3
• Limit continuous use to 2-4 weeks maximum, then implement "steroid holidays" when control is achieved to minimize the risk of pituitary-adrenal suppression and local skin atrophy. 4, 1
• In children, exercise particular caution due to increased risk of systemic absorption and potential growth interference. 4, 1

Critical pitfall to avoid: Long-term uninterrupted application of even 1% hydrocortisone to the eyelids has caused severe atrophy and telangiectasia in adult patients. 2 Intermittent therapy is essential in these vulnerable areas. 2

Essential Adjunctive Measures: Emollients and Skin Care

Emollient therapy is non-negotiable and must be continued even when eczema appears controlled:

• Apply preservative-free emollients liberally and frequently throughout the day to restore the compromised skin barrier. 1
• Apply emollients immediately after bathing or face washing to provide a surface lipid film that prevents evaporative water loss. 4, 1
• Use soap-free cleansers and avoid alcohol-containing products near the eyes and nose. 1
• If using both emollients and corticosteroids, apply the corticosteroid first, then the emollient after. 1

Managing Secondary Bacterial Infection

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

Watch for these infection signs:

• Increased crusting, weeping, pustules, or sudden worsening despite appropriate topical corticosteroid use. 1
• Golden-yellow crusting suggests Staphylococcus aureus, the most common pathogen. 4, 1

Antibiotic selection:

• Prescribe oral flucloxacillin for suspected S. aureus infection (typical adult dose: 500mg four times daily). 4, 1
• Use erythromycin for penicillin allergy or phenoxymethylpenicillin if β-hemolytic streptococci are isolated. 4, 1
• Continue topical corticosteroids during antibiotic treatment. 1

Managing Viral Infection: Eczema Herpeticum

If you observe grouped vesicles, punched-out erosions, or sudden deterioration, suspect eczema herpeticum and initiate oral acyclovir immediately—this is a medical emergency. 4, 1

• In ill or febrile patients, administer acyclovir intravenously. 4
• Refer immediately to ophthalmology if periocular involvement is suspected. 1

Second-Line Treatment: Topical Calcineurin Inhibitors

For severe periocular eczema refractory to low-potency topical corticosteroids after 4 weeks, initiate tacrolimus 0.03% ointment applied to affected eyelid skin twice daily. 1

• Tacrolimus can be increased to 0.1% potency and applied once daily to external eyelids and lid margins as an off-license treatment after ophthalmology consultation, with an 89% response rate in observational series. 1
• Arrange ophthalmology review within 4 weeks for cases treated with tacrolimus ointment to lid margins. 4, 1
• Do not use tacrolimus in patients with a history of ocular-surface herpes simplex virus or varicella zoster virus. 1
• In children aged 2-17 years, tacrolimus should only be used following advice from ophthalmology, starting with 0.03% ointment. 1

Important FDA warning: Pimecrolimus (Elidel) and tacrolimus carry warnings about potential cancer risk with long-term use, though causality has not been established. 5 Use for short periods with breaks in between, and only on areas with active eczema. 5

Managing Pruritus

For severe nighttime itching that disrupts sleep:

• Prescribe sedating antihistamines (hydroxyzine, diphenhydramine) for nighttime use only, as their therapeutic value resides primarily in sedative properties. 4, 6
• Avoid daytime use of sedating antihistamines. 4, 6
• Do not prescribe non-sedating antihistamines—they have little to no value in atopic eczema. 4, 6

For ocular itching specifically:

• Consider preservative-free antihistamine eyedrops (olopatadine twice daily, azelastine 2-4 times daily, or ketotifen twice daily) in addition to lubricants if lubricants alone are ineffective. 4, 1

When to Refer to Ophthalmology

Mandatory referrals:

• Any child under 7 years with periocular eczema due to limited ability to communicate symptoms and risk of interference with normal ocular development. 1
• Moderate-to-severe disease requiring topical corticosteroids for more than 8 weeks. 4, 1
• Treatment-resistant disease despite optimized topical therapy. 1
• Suspected eczema herpeticum (immediate referral). 1
• Cases treated with tacrolimus ointment to lid margins (within 4 weeks). 4, 1

Referral timeframes:

• Emergency (within 24 hours): Severe disease with risk to visual acuity or suspected eczema herpeticum. 4
• Urgent (within 4 weeks): Moderate-to-severe disease or tacrolimus use on lid margins. 4
• Standard/routine: Mild-to-moderate disease unresponsive to topical treatment. 4

Maintenance Therapy to Prevent Relapse

Once initial control is achieved, transition to weekend (proactive) therapy:

• Apply the low-potency corticosteroid twice weekly (e.g., Saturday and Sunday) to prevent relapse, which reduces relapse likelihood from 58% to 25% (RR 0.43,95% CI 0.32 to 0.57). 3
• Continue liberal emollient use daily throughout the maintenance phase. 1