Treatment with corticosteroid-sparing topical interventions such as cyclosporine, tacrolimus, sodium cromoglycate, and interferon alpha-2 demonstrates efficacy in improving the signs and symptoms of vernal keratoconjunctivitis (VKC) in children, as shown in a study.
“The available level I and III evidence reviewed in this assessment demonstrates that treatment for VKC with corticosteroid-sparing topical interventions such as cyclosporine, tacrolimus, interferon alpha-2b, and sodium cromoglycate in children 18 years of age and younger can be effective in reducing clinical signs and symptoms,” the investigators said.
The PubMed database was searched in August 2025 for articles published in English with no date restrictions. Fifty-six articles were identified, of which 15 met the eligibility criteria and were assigned a level of evidence rating by a panel methodologist.
Topical treatments
Nine studies had a level III rating, and six had a level I rating. The latter examined the efficacy of cyclosporine (4/6), tacrolimus (4/6), interferon alpha-2b (1/6), and sodium cromoglycate (1/6) ophthalmic preparations, while level III evidence studies (5/9) investigated outcomes following treatment with tacrolimus drops or ointment. [Ophthalmology 2026;133:764-774]
All interventions with level I and level III evidence showed improvements in clinical signs and symptoms of VKC in children regardless of medication, concentration, dosing frequency, or treatment duration. Furthermore, no significant adverse events were reported, except for application site discomfort.
Among the agents examined, topical cyclosporine was most consistent in its efficacy as a single agent, in either a low- or high-dose formulation. Tacrolimus ointment and drops were also effective, but these agents had relatively low tolerability, which can potentially reduce compliance among children.
“Although burning or pain on instillation was frequently noted, no serious adverse events were reported for any of the interventions used, indicating an acceptable safety profile in this patient population,” the investigators said.
Corticosteroids
Variations were noted in the use of corticosteroids in children with VKC. Some studies reported a washout period (Subedi and colleagues indicated 2 weeks of no use), but others did not have data on corticosteroid use (eg, Sruthi and colleagues). [Indian J Pharmacol 2020;52:476-481; Nepal J Ophthalmol 2020;12:39-47]
“Given the variability between studies, it would be difficult to make an overarching statement on the use of corticosteroids and any washout period from corticosteroid use,” the investigators said. “Additionally, there are concerns about the use of ocular surface immunosuppression with topical corticosteroids.”
Limitations
Only a few formulations of medications had been approved by the US Food and Drug Administration for use in children. Demographic differences were also observed between patients, which may have influenced the course and severity of VKC, according to the investigators.
Moreover, no consistent standard existed for the analysis of outcomes, including which signs or symptoms were examined or the scale on which they were graded.
“Overall, the different options for treatment should be discussed with patients and their families, and the clinical signs and symptoms should be monitored to determine the appropriate treatment for the individual child,” the investigators said.
“Future studies should focus on drug formulation and concentration, dosing schedule, and optimal treatment duration while also evaluating risk factors for treatment failure,” they added.