What is the best treatment approach for a patient with bilateral eyelid eczema, characterized by erythematous and swollen eyelids with dry skin, exacerbated by cold air or air conditioning exposure?

Treatment of Bilateral Eyelid Eczema

Start with hydrocortisone 1% ointment applied twice daily to the affected eyelid skin for 2-4 weeks, combined with liberal emollient application throughout the day, and if this fails or chronic treatment is needed, switch to tacrolimus 0.1% ointment once daily. 1, 2

First-Line Treatment Protocol

• Apply hydrocortisone 1% (or equivalent low-to-moderate potency corticosteroid) to the erythematous, swollen eyelid skin twice daily for a maximum of 2-4 weeks 1, 2

• Apply emollients liberally and frequently to the periocular area, even when the eczema appears controlled, to restore the compromised skin barrier—this is particularly important given the exacerbation by cold air and air conditioning 1, 2

• Use soap-free cleansers and avoid alcohol-containing products near the eyes, as these can further disrupt the already compromised barrier 1, 2

• Implement short "steroid holidays" when disease is controlled to minimize side effects including skin atrophy and potential systemic absorption 2

Critical Safety Warning

• Never use potent or very potent corticosteroids around the eyes—the thin eyelid skin has exceptionally high risk for atrophy, telangiectasia, glaucoma, and cataracts 1, 2

• In the context of cold air/air conditioning exacerbation, counsel the patient to wear protective eyewear or sunglasses as a physical barrier when exposed to these environmental triggers 3

Second-Line Treatment for Inadequate Response

If symptoms persist after 2-4 weeks of hydrocortisone or if chronic maintenance therapy is required:

• Switch to tacrolimus 0.1% ointment applied once daily to the external eyelids and lid margins—this demonstrates an 89% response rate for eyelid eczema 1, 2

• Tacrolimus can be applied directly to the ocular surface of the lids for best effect, though this is typically initiated by ophthalmology 3, 2

• Do not use tacrolimus in patients with a history of ocular-surface herpes simplex virus or varicella zoster virus 3, 1, 2

• Arrange ophthalmology review within 4 weeks when initiating tacrolimus 3

Managing Concurrent Ocular Surface Symptoms

Given the bilateral presentation with swelling and environmental triggers, consider concurrent dry eye:

• Add preservative-free hyaluronate eyedrops 2-4 times daily if dry eye symptoms are present (burning, foreign body sensation, tearing) 1, 2, 4

• If inflammation is moderate or lubricants alone are ineffective, trial olopatadine antihistamine eyedrops twice daily in addition to lubricants 1, 2

• Cold compresses and refrigerated artificial tears can provide symptomatic relief, particularly given the cold air exacerbation pattern 3

Monitoring for Secondary Bacterial Infection

• Watch for increased crusting, weeping, pustules, or sudden worsening suggesting bacterial superinfection (most commonly Staphylococcus aureus) 2, 4

• If bacterial infection is suspected, prescribe oral flucloxacillin (or erythromycin if penicillin-allergic) 1, 2, 4

• Continue topical corticosteroids during bacterial infection when appropriate systemic antibiotics are given concurrently—do not delay corticosteroids when infection is present 2, 4

Mandatory Ophthalmology Referral Criteria

Refer to ophthalmology if:

• Moderate-to-severe disease requiring topical corticosteroids for more than 8 weeks 1, 2, 4

• Treatment-resistant disease despite optimized topical therapy with both corticosteroids and tacrolimus 2, 4

• When initiating tacrolimus to lid margins for optimal effect 2, 4

• Any visual symptoms, eye pain, or suspected ocular surface involvement beyond dry eye 2

Common Pitfalls to Avoid

• Never use continuous corticosteroid therapy without breaks—implement treatment holidays when disease is controlled to prevent skin atrophy and systemic effects 1, 2

• Avoid indiscriminate use of topical antibiotics without clear indication, as they can induce contact dermatitis and toxicity 2

• Do not overlook potential contact allergens—if the condition is refractory to standard treatment, consider patch testing for metals (nickel, cobalt), fragrances, preservatives, and cosmetics, which are the most common culprits in eyelid allergic contact dermatitis 5, 6, 7