What topical treatment can be used around the eyes for a patient with a worsening periorbital rash, already on multiple treatments from an allergist, who is being given a single 8mg dose of Decadron (dexamethasone)?

From the Guidelines

For a worsening rash around the eyes after a single 8mg dose of decadron in the ER, I recommend prescribing tacrolimus ointment for application to the lid margins, as suggested by the most recent expert consensus 1. This approach is based on the latest guidance from the British Journal of Dermatology, which recommends offering tacrolimus ointment to adults and children (> 7 years) with dupilumab-related ocular surface disorders, including blepharitis, if this has not been tried previously 1. Key considerations for managing the rash around the eyes include:

• Avoiding tacrolimus ointment if it has been tried for 2–4 weeks and has been ineffective, or if it has not been tolerated 1
• Considering short-term ocular topical corticosteroids, such as preservative-free dexamethasone 0.1%, prednisolone 0.5%, or hydrocortisone 0.335% eyedrops, for people with moderate-to-severe ocular surface disorders 1
• Instructing patients to apply warm compresses to the eyelids for several minutes to soften adherent scurf and scales or discharge and/or warm the meibomian secretions, as recommended by the American Academy of Ophthalmology 1
• Advising patients to follow up with their allergist within 1-2 weeks, or sooner if the rash worsens or if they develop eye pain, vision changes, or severe swelling. It is essential to prioritize the patient's safety and well-being, and to carefully consider the potential risks and benefits of each treatment option, particularly when managing delicate areas like the eyelids.

From the FDA Drug Label

When using this product avoid contact with eyes The FDA drug label does not answer the question.

From the Research

Treatment Options for Rash Around Eyes

Given the patient's presentation of a worsening rash around the eyes despite multiple treatments from an allergist, and the decision to administer an 8mg dose of Decadron, the following options can be considered for home use around the eyes:

• Topical corticosteroids, as they are the first-line treatment for atopic dermatitis flare-ups 2
• Topical calcineurin inhibitors such as pimecrolimus and tacrolimus, which can be used in conjunction with topical corticosteroids 2
• Emollients, which are recommended for maintenance therapy to help maintain the skin's barrier function 2

Considerations for Topical Corticosteroid Use

When prescribing topical corticosteroids for use around the eyes, it is essential to consider the following:

• The risk of adverse effects increases with prolonged use, large area of application, higher potency, occlusion, and application to areas of thinner skin such as the face and genitals 3
• Lower potencies and shorter durations should be used when prescribing topical corticosteroids for children 3
• Correct patient application is critical to successful use, and patients may be taught application using the fingertip unit method 3

Allergic Contact Dermatitis

It is also important to consider the risk of allergic contact dermatitis due to topical application of corticosteroids, which can be tested with delayed hypersensitivity patch testing 4

• Cross-reactivity among topically administered corticosteroids is frequent and often can be predicted on the basis of additional patch testing and an established classification scheme 4

Moisturizer Therapy

Moisturizer therapy may be beneficial in managing atopic dermatitis, but its role in preventing atopic dermatitis and food allergy is still unclear, with some studies suggesting that it may be ineffective or even increase the risk of allergy development 5