What is the best treatment approach for a patient with periorificial dermatitis under the eye?

Treatment of Periorificial Dermatitis Under the Eye

For periorificial dermatitis affecting the periocular area, initiate treatment with tacrolimus 0.1% ointment applied once daily to the external eyelids and lid margins for 2-4 weeks, combined with discontinuation of all topical corticosteroids and facial products. 1, 2

Initial Management Approach

Immediate cessation of aggravating factors is essential:

• Discontinue all topical corticosteroids immediately, as these are the most common precipitant of periocular periorificial dermatitis 2, 3
• Eliminate all facial and eye care products that may contain irritants, fragrances, or preservatives 2
• Replace soaps and detergents with gentle emollients to restore the impaired epidermal barrier 2, 4

Critical pitfall: Many patients will experience a rebound phenomenon after stopping topical steroids, requiring close follow-up during the initial 1-2 weeks. Warn patients about temporary worsening before improvement occurs. 5

First-Line Active Treatment

Tacrolimus ointment is the preferred first-line therapy for periocular involvement:

• Apply tacrolimus 0.1% ointment once daily directly to external eyelids including lid margins for 2-4 weeks 1, 6, 2
• For children aged 2-17 years, use tacrolimus 0.03% ointment instead, ideally with ophthalmology guidance 1, 6, 2
• Tacrolimus demonstrates an 89% response rate for eyelid eczema and avoids the risks of skin atrophy, telangiectasia, and elevated intraocular pressure associated with corticosteroids 1

Absolute contraindication: Do not use tacrolimus in patients with a history of ocular-surface herpes simplex virus or varicella zoster virus, as it increases susceptibility to herpes simplex keratitis and eczema herpeticum 1, 6, 2

Mandatory ophthalmology referral: Arrange ophthalmology review within 4 weeks when initiating tacrolimus treatment, particularly in children under 7 years or when applying medications to lid margins 1, 6, 2

Second-Line Treatment for Refractory Cases

If tacrolimus fails or is contraindicated, consider short-term low-potency topical corticosteroids:

• Hydrocortisone 1% applied twice daily for a maximum of 2-4 weeks is the safest corticosteroid option for the thin periocular skin 1
• Eight weeks is the absolute maximum duration for corticosteroid treatment, even in severe cases 2
• Combine with liberal emollient application using soap-free cleansers and avoiding alcohol-containing products 1

For moderate-to-severe disease requiring prolonged treatment:

• Use preservative-free dexamethasone 0.1% or hydrocortisone 0.335% eyedrops if ocular surface involvement is present 1, 2
• Introduce corticosteroid-sparing agents early (such as ciclosporin drops) to facilitate tapering 1, 2

Adjunctive Supportive Measures

All patients should receive:

• Preservative-free ocular lubricants applied frequently to support the tear film 2
• Lid hygiene with warm compresses and commercially available lid wipes 2
• Cold compresses and refrigerated artificial tears for symptomatic relief 2

Avoid topical antibiotics routinely: These are not indicated for uncomplicated periorificial dermatitis and can cause allergic contact dermatitis themselves 2

Treatment-Resistant Disease Algorithm

If standard therapy fails after 8 weeks:

1. Consider combination treatment with topical corticosteroids, tacrolimus ointment, and ciclosporin drops 2
2. Refer to ophthalmology for consideration of autologous or allogeneic serum eyedrops at specialized centers 2
3. Arrange patch testing to identify specific allergens (fragrances, preservatives, drugs in cosmetics and eye drops) 2

Mandatory ophthalmology referral criteria:

• Moderate-to-severe disease requiring corticosteroids beyond 8 weeks 1, 2
• Treatment-resistant disease despite appropriate therapy 1, 2
• Any suspected ocular surface involvement beyond simple dermatitis 2
• All children under 7 years with periocular involvement 1

Monitoring for Complications

Watch for secondary bacterial infection:

• Signs include increased crusting, weeping, or pustule formation 1
• Treat with oral flucloxacillin or erythromycin if infection develops 1

Monitor for corticosteroid adverse effects if used:

• Check intraocular pressure in patients on prolonged corticosteroid therapy 7
• Minimize periocular steroid duration due to unclear associations with cataracts and glaucoma 1