An 80-year-old man presents with a history of periocular and hand dermatitis for several months. A detailed history of his exposures and all eye medications is obtained, and the cause of his dermatitis is still not elicited. He is patch-tested and found to have a reaction to epoxy resin—a type of glue found in artificial nails. Despite this finding, the patient still denies exposures to any types of glue. His dermatitis is treated and resolved. The patient is so pleased, he builds a wooden end table with an inscription, "The best doctor". It is only after presenting this gift to his dermatologist, that they realize the glue the patient had been exposed to was the glue used for his hobby: woodworking.

A middle-aged woman presented with a several year history of intermittent urticaria and puffy eyelids. In between these episodes, she had long periods without outbreaks. A detailed history of her exposures, cosmetics and medications did not reveal any correlation for her intermittent episodes of dermatitis. After patch testing, it was discovered that she was allergic to neomycin. The woman worked in an office and experienced intermittent paper cuts. Every time she had a paper cut, she placed neomycin on the cut and reacted to the neomycin.

Indeed the itchy, swollen, red eyelid can be a perplexing diagnostic and therapeutic challenge for the general ophthalmologist. Although most ophthalmologists assume that the cause of dermatitis in the eyelids is topical medications, contact dermatitis from other sources is more common. Contact dermatitis of the eyelid is the most common cause of eyelid dermatitis, with prevalence variously cited at 65.3 percent, 72 percent and 74 percent.^1-3 Many dermatologists feel that the average time to diagnosis of contact dermatitis of the eyelid can be as long as seven years.

Figure 1. A patient with itchy, swollen, erythematous eyelids after using topical antibiotic solution post-cataract extraction. (All images courtesy Daniel Shaw, MD.)

The unique skin of the eyelid with its thin epidermis, small amount of fat and high vascularity makes it more sensitive to allergens and irritants. The fact that the eyelid tissue is more prone to contact dermatitis can add to the mystery of finding the etiology. Nail enamel can cause eyelid dermatitis, while the skin surrounding the fingernails remains clear, and shampoo can cause eyelid dermatitis while the scalp remains unaffected.

Eyelid allergic dermatitis often presents with erythema, edema, scaling of the eyelid skin as well as with symptoms of itching and burning. The vast majority (80 to 90 percent) of affected patients are female.⁴ The majority of periocular dermatitis is not from direct ocular exposure, but rather indirect extraocular contact.³

• Ophthalmic solutions. The preservative benzalkonium chloride, a well-known skin irritant, is very widely used in ophthalmic therapeutic preparations. The list includes atropine, homatropine, gentamicin, Tobradex, maxitrol, Alphagan, pilocarpine, timolol, Xalatan, Patanol, proparacaine, phenylephrine and tropicamide. Actually, it is harder to find an ophthalmic solution that does not have benzalkonium chloride than one with it. If such an allergy is suspected, care must be taken to prescribe preservative-free medications for the patient (See Figure 1).⁵

• Cosmetics. The published percentage of eyelid contact dermatitis patients from cosmetics has been cited as high as 29 percent.³ It is more often caused by indirect contact with cosmetics from the face, fingernails, or hair. Cocamidopropyl betaine (CAPB) is a common chemical allergen found in shampoo, Dove soap, makeup remover, eye cosmetics and even contact lens solution. You should also remember that makeup brushes and applicators may also cause contact dermatitis.^3,5,6

Figure 2. A patient with a history of chronic erythema, itching and puffiness of the eyelids. On patch testing, the patient was found to be allergic to fingernail polish.

• Nails. Ophthalmologists may frequently forget the nails as a source of eyelid dermatitis. Nail lacquer, methacrylates and cyanoacrylates, which are ingredients in artificial nails, are all materials that may cause eyelid contact dermatitis with or without changes in the patient's nail beds. Acrylates are also found in eyeglass frames (See Figure 2).^3,5,6

 • Metals. A common allergen found in eyelash curlers, mascara, eye shadow, contact lens cleaning solutions and eyebrow pencils is nickel. Nickel is a common allergen, and direct contact can cause an eyelid dermatitis. You should also remember that hand transfer from a metal nail file, occupational metal exposure, or jewelry placed on the hands and fingers can also cause eyelid dermatitis.^3,5,6

 • Hair dye. A chemical allergen found in hair dye is paraphenylenediamine (PPD). It can also be found in textile or fur dyes, cosmetics, henna tattoos, inks, photography film, black rubber, oils and gasoline. PPD is commonly found in hair dye and you should elicit this history from the patient. Further, occupational allergy can be found in hairdressers and those working with printing inks and film. As with the other allergens, the presentation may be localized to upper eyelid dermatitis with or without involvement of the scalp and face.^3,6

When approaching the patient with eyelid contact dermatitis, it is helpful to remember not to limit the suspected allergens to those in direct contact with the eyes. The majority of causes for periocular dermatitis are extraocular contacts. Obtaining a detailed history is essential, including a history of known allergies, all cosmetics and toiletries, ophthalmic solutions, occupational and leisure exposures. It is often helpful to ask the patient to bring in all products applied to the hands, body and face. Examine the patient's nails. If the history and exam do not elicit the allergen, patch testing needs to be considered.^3,5,6

 • Patch testing. If the culprit is not evident by history taking, you should consider referring to a dermatologist for the testing of preservatives and vehicles of cosmetics, nail polish, shampoos, sprays, eye drops and contact lens cleaning solutions.

Figure 3. Patch testing performed on a patient's back. Allergens are applied to the back and remain there for 48 to 96 hours. Ophthalmic preparations may not penetrate the back skin readily and may require high concentrations or erosions on the skin for increased penetration so that patch testing can be performed accurately.

Formal patch testing should be performed by experienced physicians. With patch testing, the allergens are applied to the back and remain there for 48 to 96 hours (See Figure 3). Ophthalmic preparations may not penetrate the back skin as readily, and may need either to be tested at higher concentrations, or a dermatologist may need to create erosions on the skin to increase the penetration of ocular solutions.⁵

• Treating the patient. The key to treatment is cessation and avoidance of the offending agent. Cool compresses help provide relief of symptoms. Corticosteroid use on the eyelid has been associated with skin atrophy, glaucoma, cataracts and increased susceptibility to infections. So utmost caution should be employed when considering the use of corticosteroids in the periocular area.^3,5,6 A safer, effective treatment is the topical immunomodulators, such as tacrolimus (Protopic) or pimecrolimus (Elidel).⁵ These can be used twice daily to the affected area until the rash clears. They are safe to use around the eyes and do not have the side effects associated with topical corticosteroid use. If these medications are ineffective, one can consider the use of a mild topical steroid ointment, up to a class V (i.e. Synalar), for a short period of five to seven days. Stronger steroids should be avoided.

Contact dermatitis of the perio-ocular area can be a frustrating and perplexing problem for both the doctor and the patient. Lack of recognition of the clinical signs of this entity often results in delayed diagnosis. Once the diagnosis is made, attention should be focused on all items that may be in contact with the eyelid skin and not just topical medications. Patch testing by an experienced dermatologist is often helpful when clinical history and examination are not adequate for diagnosis. Avoidance of the offending agent is the primary treatment modality. In addition, topical medications, such as topical immunomodulators, are often helpful for controlling these types of conditions.  REVIEW