What is the recommended treatment for periorbital eczema?

Treatment of Periorbital Eczema

Topical calcineurin inhibitors, specifically tacrolimus ointment, are the first-line therapy for periorbital eczema, with tacrolimus 0.1% applied once daily to external eyelids including lid margins for 2-4 weeks in adults, and 0.03% for children aged 2-17 years. 1, 2

First-Line Treatment: Topical Calcineurin Inhibitors

• Tacrolimus 0.1% ointment once daily for adults applied directly to external eyelids and lid margins for 2-4 weeks is the preferred initial therapy 1, 2
• Tacrolimus 0.03% ointment for children aged 2-17 years, ideally following ophthalmology consultation 1, 2
• Calcineurin inhibitors can be applied directly to the ocular surface of the lids for optimal effect, though this is typically initiated by ophthalmology 1
• These agents are particularly valuable for periorbital eczema because they avoid the risks of topical corticosteroids in this sensitive area 3

Critical Safety Contraindications

• Never use tacrolimus in patients with a history of ocular-surface herpes simplex virus or varicella zoster virus 1, 2
• Arrange ophthalmology review within 4 weeks when initiating periocular treatments, particularly in children or when applying medications to lid margins 1
• Never use intralesional steroids in the periorbital area due to severe risks including central retinal artery embolism, hypopigmentation, fat atrophy, and full-thickness eyelid necrosis 2

Adjunctive Measures for All Patients

• Replace all soaps and detergents with dispersible cream as a soap substitute to avoid removing natural lipid from already-dry skin 4
• Keep nails short to minimize trauma from scratching 4
• Avoid irritant clothing such as wool next to the skin; cotton is preferred 4
• Apply emollients after bathing to provide a surface lipid film that retards evaporative water loss 4

When Topical Corticosteroids Are Necessary

If calcineurin inhibitors fail or are contraindicated, topical corticosteroids may be used with extreme caution:

• Use the least potent preparation required to control the eczema 4
• Apply no more than twice daily; some newer preparations require only once daily application 4
• Very potent and potent categories should be used with caution for limited periods only due to risk of pituitary-adrenal axis suppression, particularly concerning in children where growth interference may occur 4
• Stop corticosteroids for short periods when possible 4

Managing Secondary Infection

• Flucloxacillin is the first-choice antibiotic for treating secondary bacterial infection with S. aureus, the most common pathogen 4
• Phenoxymethylpenicillin if β-hemolytic streptococci are isolated 4
• Erythromycin for flucloxacillin resistance or penicillin allergy 4
• If eczema herpeticum develops, give oral acyclovir early; use intravenous acyclovir in ill, feverish patients 4

Adjunctive Therapy for Severe Pruritus

• Sedating antihistamines are useful as short-term adjuvants during relapses with severe pruritus; their value resides principally in sedative properties 4
• Use at nighttime only; avoid daytime use 4
• Non-sedating antihistamines have little or no value in atopic eczema 4
• Large doses may be required in children 4

Common Pitfalls to Avoid

• Do not undertreat due to steroid phobia—this is a major cause of treatment failure, but in the periorbital area, calcineurin inhibitors should be first-line to avoid this dilemma entirely 4
• Avoid all irritants including soaps, detergents, and excessive water exposure 2
• Do not use hydrocortisone as first-line therapy; over 80% of patients using topical hydrocortisone experience refractory episodes 5
• Recognize that allergic contact dermatitis is the most common cause of periorbital dermatitis (32-44% of cases), followed by atopic eczema (14-25%), so patch testing may be necessary if standard treatment fails 3

When to Refer

Failure to respond to first-line treatment with calcineurin inhibitors and emollients is an indication for specialist referral 4. The specialist should reinforce compliance with first-line measures before escalating to second-line treatments 4.