What is the cause and appropriate treatment for itchy red skin around the eyes without sclera involvement?

Itchy Red Skin Around Eyes Without Scleral Involvement

This presentation most likely represents periocular allergic dermatitis or atopic dermatitis, and should be treated initially with preservative-free ocular lubricants plus topical antihistamine drops (olopatadine), with escalation to tacrolimus 0.1% ointment applied to the eyelid margins if symptoms persist beyond 48-72 hours. 1, 2

Initial Assessment and Differential Diagnosis

The absence of scleral involvement is critical—this distinguishes eyelid dermatitis from conjunctivitis and suggests the pathology is limited to the periocular skin rather than the ocular surface itself. 3

Key diagnostic considerations include:

• Allergic contact dermatitis (most common cause of isolated eyelid involvement without conjunctival signs) 3
• Atopic dermatitis with periocular extension 1, 3
• Seborrheic dermatitis (though typically less pruritic) 3
• Contact urticaria from cosmetics, topical medications, or environmental allergens 3

Red flags requiring urgent ophthalmology referral within 24 hours:

• Any visual changes or pain 1
• Vesicular lesions suggesting herpes simplex or zoster 4
• Purulent discharge 5
• Corneal involvement 5

First-Line Treatment Algorithm

Step 1: Immediate Symptomatic Relief (All Patients)

• Cold compresses applied to closed eyelids for immediate symptom relief 1, 2
• Preservative-free artificial tears 4 times daily to dilute any allergens on the ocular surface 1, 2
• Allergen avoidance: Remove potential triggers including eye makeup, facial creams, and airborne allergens; implement hypoallergenic bedding and eyelid cleansers 1, 2
• Counsel against eye rubbing, which worsens inflammation and can lead to keratoconus in atopic patients 1, 2

Step 2: Pharmacologic Treatment for Mild-to-Moderate Disease

Start dual therapy immediately: 1, 2

• Preservative-free ocular lubricants 2-4 times daily 1
• Topical antihistamine drops (olopatadine or ketotifen) twice daily 1, 2

Critical point: Preservative-free formulations are mandatory because patients with eyelid dermatitis have increased risk of allergic contact dermatitis to preservatives. 1

Store eye drops in the refrigerator for additional cooling relief upon instillation. 1, 2

Escalation for Inadequate Response (48-72 Hours)

Step 3: Add Topical Calcineurin Inhibitor

If symptoms persist after 48-72 hours on lubricants plus antihistamines:

For adults: 1

• Tacrolimus 0.1% ointment applied once daily to eyelid margins (not directly in the eye)
• Continue preservative-free lubricants and antihistamine drops
• Refer to ophthalmology for assessment within 4 weeks when starting tacrolimus 1

For children ages 2-15 years: 1

• Tacrolimus 0.03% ointment to eyelid margins
• Seek ophthalmology advice before initiating tacrolimus in children ages 7-17 years 1

For children under 7 years: 1

• Immediate ophthalmology referral for severity grading and treatment guidance

Important caveat: Tacrolimus may increase susceptibility to herpes simplex keratitis, so exclude herpetic infection before starting. 1

When to Use Topical Corticosteroids (Use Sparingly)

Topical corticosteroids should be reserved for severe cases only and used as a bridge therapy, not first-line treatment for isolated eyelid dermatitis. 1

If corticosteroids are necessary: 1, 2

• Use preservative-free dexamethasone 0.1% or loteprednol etabonate (lower side-effect profile)
• Maximum duration: 1-2 weeks only 1, 2
• Mandatory monitoring: Baseline and periodic intraocular pressure measurement plus pupillary dilation to evaluate for glaucoma and cataract 1, 2
• Start tacrolimus early as a corticosteroid-sparing agent to facilitate tapering 1

Critical Pitfalls to Avoid

Never use punctal plugs in patients with periocular allergic disease—they prevent flushing of allergens and inflammatory mediators. 1, 2

Avoid oral antihistamines as primary treatment—they worsen dry eye syndrome and impair the tear film's protective barrier, potentially exacerbating symptoms. 1, 2

Do not use chronic vasoconstrictors (naphazoline/pheniramine combinations)—prolonged use beyond 10 days causes rebound hyperemia (conjunctivitis medicamentosa). 1, 2

Avoid indiscriminate topical antibiotics—they provide no benefit for allergic/atopic disease, induce toxicity, and contribute to resistance. 2

Special Considerations for Atopic Dermatitis Patients

If the patient has known atopic dermatitis, the periocular involvement represents extension of their systemic disease. 6, 7

Enhanced skin barrier restoration is essential: 7

• Emollients applied to periocular skin (avoiding direct eye contact)
• Maintain acidic pH of skin
• Address Staphylococcus aureus colonization if present

For patients on dupilumab: 1

• This presentation may represent dupilumab-related ocular surface disorder (DROSD)
• Follow the specific DROSD treatment algorithm with early ophthalmology involvement
• Consider dupilumab dose reduction (300 mg every 3 weeks) if skin disease is well-controlled 1

When to Refer to Ophthalmology

Urgent referral (within 24 hours): 1

• Severe symptoms with visual changes
• Suspected infection (vesicles, purulent discharge)
• Children under 7 years with any severity

Standard referral (within 4 weeks): 1

• Mild-to-moderate disease not responding to lubricants plus antihistamines
• When initiating tacrolimus ointment
• Any patient requiring topical corticosteroids

Consider patch testing if contact allergen is suspected and symptoms are refractory, though the evidence for this approach in isolated eyelid dermatitis is limited. 1