Treatment for Eczema Around the Eyes

First-Line Treatment Approach

The American Academy of Dermatology recommends starting with topical corticosteroids as first-line therapy, using the lowest potency that controls symptoms, applied no more than twice daily to the periocular area, with special caution given the thin skin around the eyes 1, 2
Apply low-to-moderate potency topical corticosteroids to affected eyelid skin twice daily maximum, as suggested by the British Association of Dermatologists 1, 2
Avoid very potent or potent corticosteroids around the eyes due to the high risk of skin atrophy in this thin-skinned area, as advised by the National Institute for Health and Care Excellence 1
Use the least potent preparation that achieves control, and implement short "steroid holidays" when possible to minimize side effects including pituitary-adrenal suppression, as recommended by the American Academy of Dermatology 1, 2
In children, use topical corticosteroids with particular caution due to increased risk of systemic absorption and growth interference, as cautioned by the American Academy of Pediatrics 1, 3

Apply emollients liberally and regularly to the periocular area, even when eczema appears controlled, to restore the skin barrier, as suggested by the National Eczema Association 2
Use soap-free cleansers and avoid alcohol-containing products near the eyes, as recommended by the American Academy of Dermatology 2
Apply emollients after bathing to provide a surface lipid film that prevents water loss, as advised by the British Association of Dermatologists 1, 2

Watch for signs of bacterial superinfection, such as increased crusting, weeping, or pustules around the eyes, as suggested by the Infectious Diseases Society of America 2
Prescribe oral flucloxacillin for suspected Staphylococcus aureus infection, the most common pathogen, as recommended by the American Academy of Dermatology 1, 2, 3
Continue topical corticosteroids during bacterial infection when appropriate systemic antibiotics are given concurrently, as advised by the National Institute for Health and Care Excellence 2
If you observe grouped vesicles, punched-out erosions, or sudden deterioration, suspect eczema herpeticum and initiate oral acyclovir immediately, as recommended by the American Academy of Dermatology 1, 2, 3

For severe atopic eyelid disease refractory to topical corticosteroids, initiate tacrolimus 0.03% ointment applied to affected eyelid skin twice daily, as suggested by the British Association of Dermatologists 4
Tacrolimus can be increased to 0.1% potency as an off-license treatment in appropriate cases after ophthalmology consultation, as recommended by the Royal College of Ophthalmologists 5
Consider ciclosporin eyedrops for patients with concurrent ocular surface involvement, though this should typically be initiated by ophthalmology, as advised by the American Academy of Ophthalmology 4, 5

Never delay topical corticosteroids when infection is present, as they remain primary treatment when appropriate systemic antibiotics are given, as recommended by the National Institute for Health and Care Excellence 2
Do not use potent or very potent corticosteroids around the eyes due to high risk of skin atrophy and ocular complications, as cautioned by the American Academy of Dermatology 1
Avoid continuous corticosteroid use without breaks, implement treatment holidays when disease is controlled, as advised by the American Academy of Dermatology 1, 2

Refer any child under 7 years with periocular eczema to ophthalmology due to limited ability to communicate symptoms and risk of interference with normal ocular development, as recommended by the American Academy of Pediatrics 4, 5
Refer moderate-to-severe disease requiring topical corticosteroids for more than 8 weeks, as suggested by the British Association of Dermatologists 4
Refer treatment-resistant disease despite optimized topical therapy, as advised by the National Institute for Health and Care Excellence 4, 5
Refer immediately if eczema herpeticum is suspected, as recommended by the American Academy of Dermatology 1, 2

The British Association of Dermatologists recommends applying tacrolimus 0.03% ointment to affected eyelid skin twice daily for severe atopic eyelid disease refractory to topical corticosteroids 6, 7
Tacrolimus 0.1% ointment applied once daily to the external eyelids and lid margins can be used as an off-license treatment in appropriate cases, typically after ophthalmology consultation, with a response rate of 89% in observational series 6, 7
The British Association of Dermatologists advises against using tacrolimus in patients with a history of ocular-surface herpes simplex virus or varicella zoster virus 6, 7
In children aged 2-17 years, tacrolimus should only be used following advice from ophthalmology, starting with 0.03% ointment 6, 7

The British Association of Dermatologists suggests using preservative-free hyaluronate eyedrops applied 2-4 times daily for patients with concurrent ocular surface involvement or dry eye symptoms, with higher hyaluronate percentages offering greater therapeutic efficacy 7, 8
Olopatadine antihistamine eyedrops twice daily may be trialed in addition to lubricants if lubricants alone are ineffective 7, 8
Ciclosporin eyedrops for severe keratitis should typically be initiated by ophthalmology 6, 7

Arrange ophthalmology review within 4 weeks for cases treated with tacrolimus ointment to lid margins 6, 7