What is the recommended treatment approach for a patient with periocular dermatitis using tacrolimus (immunosuppressive medication) cream?

Tacrolimus Cream for Periocular Dermatitis

Tacrolimus 0.1% ointment applied once daily to the external eyelids and lid margins for 2-4 weeks is the recommended treatment for periocular dermatitis, showing an 89% response rate in observational studies. 1

Initial Foundation Therapy (Start Immediately)

• Apply preservative-free ocular lubricants 2-4 times daily to all affected periocular areas as the foundation of therapy, which provides symptomatic relief and supports the ocular surface. 1
• Implement eyelid hygiene with warm compresses for 5-10 minutes, 3-4 times daily, followed by gentle cleansing using diluted baby shampoo or hypochlorous acid 0.01% eye cleaners on a cotton swab. 1
• Continue lubricants and hygiene measures throughout tacrolimus treatment as these are complementary therapies, not alternatives. 1

Primary Treatment: Tacrolimus Ointment

Adult Dosing (≥16 years)

• Apply tacrolimus 0.1% ointment once daily to the external eyelids and lid margins for 2-4 weeks. 1
• The ointment can be applied directly to the ocular surface of the lids (off-license use) for best effect, though this is typically initiated by ophthalmology. 1
• Arrange ophthalmology review within 4 weeks for all patients using tacrolimus on lid margins, but do not delay starting treatment while awaiting this appointment. 1

Pediatric Dosing (2-17 years)

• Start with tacrolimus 0.03% ointment for children aged 2-17 years, applied once daily. 1
• Increasing to tacrolimus 0.1% ointment is acceptable as off-license treatment in appropriate cases, but should only be done following ophthalmology advice. 1
• Ophthalmology consultation is mandatory before initiating tacrolimus in pediatric patients. 1

Evidence Supporting Tacrolimus

The 2024 British Journal of Dermatology expert consensus analyzed observational series showing tacrolimus ointment had the highest response rate (89%) among all topical treatments for periocular inflammatory conditions, outperforming corticosteroid eyedrops (74%), lubricants alone (65%), and ciclosporin eyedrops (63%). 1 A 2024 prospective case series demonstrated that tacrolimus 0.1-0.03% applied twice daily for 1-4 weeks showed promising outcomes in periorbital atopic dermatitis in both adults and children. 2 An open-label trial of 20 patients with moderate to severe eyelid dermatitis found that 80% experienced marked improvement or better after 8 weeks of tacrolimus 0.1% twice daily, with no significant increase in intraocular pressure or development of cataracts or glaucoma. 3

Critical Safety Contraindications

• Do not use tacrolimus in patients with a history of ocular-surface herpes simplex virus or varicella zoster virus, as these agents may increase susceptibility to herpes simplex keratitis. 1
• Warn patients about potential rosaceiform dermatitis as a complication, which can develop within 2-3 weeks of treatment, particularly in patients with a history of rosacea or acne. 4
• Advise patients that local burning and itching are common after the first few applications (60% report burning, 25% report itching) but are typically transient. 3

Escalation for Inadequate Response

If No Response After 2-4 Weeks

• Discontinue tacrolimus and refer to ophthalmology for consideration of alternative treatments. 1
• Ophthalmology may initiate preservative-free corticosteroid eyedrops (dexamethasone 0.1%, prednisolone 0.5%, or hydrocortisone 0.335%) for moderate-to-severe cases. 1
• Limit corticosteroid use to a maximum of 8 weeks due to risks of increased intraocular pressure, cataract formation, skin atrophy, and telangiectasia. 1

For Treatment-Resistant Cases

• Consider combination tacrolimus ointment and topical ciclosporin drops for refractory cases, though ciclosporin should typically be initiated by ophthalmology. 1
• Topical ciclosporin 0.05% eyedrops at least four times daily have demonstrated efficacy in severe allergic conjunctivitis and may allow for reduced corticosteroid use. 1

Adjunctive Symptomatic Treatment

• Add topical antihistamine eyedrops (olopatadine twice daily, ketotifen twice daily, or azelastine 2-4 times daily) for patients with moderate itching or inadequate response to lubricants alone. 1
• These should be used in addition to, not instead of, ocular lubricants and tacrolimus. 1
• Note that antihistamine eyedrops are unlikely to be beneficial for children aged <7 years and should not delay ophthalmology referral. 1

Follow-Up Protocol

• Reassess at 4 weeks during ophthalmology review for all patients on tacrolimus ointment. 1
• If using corticosteroids, monitor regularly for signs of skin atrophy, increased intraocular pressure, glaucoma, and cataracts with baseline and periodic IOP measurements and pupillary dilation. 1
• Consider alternative diagnosis or specialist referral if no improvement after appropriate trial of tacrolimus. 1

Common Pitfalls to Avoid

• Never use preservative-containing formulations, as preservatives can cause additional allergic contact dermatitis and worsen ocular surface irritation. 1
• Do not delay ophthalmology referral to assess tacrolimus response—refer within 4 weeks regardless of treatment response. 1
• Avoid long-term topical corticosteroids on eyelids due to high risk of skin atrophy, telangiectasia, increased intraocular pressure, and cataract formation. 1
• Do not abruptly discontinue high-potency corticosteroids if previously used, as rebound flare may occur; transition to tacrolimus or other appropriate alternative. 1