Dermatology disorders can have numerous ocular symptoms

Common dermatological disorders can manifest with mild to severe ocular symptoms that can result in corneal damage.

John D. Ng

Diagnosing and treating the ocular symptoms of common skin disorders can be important in preventing corneal damage, according to experts in the field.

It is estimated that 14 million Americans have acne rosacea and 15 million have symptoms of atopic dermatitis. Another 100,000 have cancerous lid masses, while 1 in 8,000 to 1 in 46,000 have the autoimmune skin disease ocular cicatricial pemphigoid.

John D. Ng, MD, FACS, said that despite the high prevalence of dermatological disorders and diseases, there is a high incidence of underdiagnosis of these conditions.

“I would say almost 30% of patients in my clinic have some form of rosacea,” he said in a telephone interview with Ocular Surgery News. “If it’s really mild and they don’t have any complaints, then I briefly mention it to them, but it is very common. One typical question that I get is, ‘How come no one ever told me this before?’ I think that’s because we don’t have a high index of suspicion. I think we just need to be aware of that and that it can cause problems.”

Acne rosacea

Acne rosacea is a chronic inflammatory condition that affects the skin and oil glands. Dr. Ng said the meibomian glands in the eyelid, which produce the oil component of the tear film, are affected in rosacea, causing dilated vessels and flushing on the face and the eyelid margins.

Ocular symptoms include chronic red eyes, styes, chalazia and severe photophobia. Patients can develop infiltrative keratitis and scarring of the cornea. About 50% of patients who have acne rosacea have ocular symptoms, and 20% of patients have been diagnosed because of their eye problems.

The average age of patients with acne rosacea is between 30 and 50 years, and more women are affected than men. Rosacea is most common in light-skinned, blue-eyed people from Scandinavian and Northern European countries, although Dr. Ng said he has treated Asians with meibomianitis.

He said significant ocular rosacea can have an inflammatory component with recurrent Staph infection. Patients’ eyelid margins typically look pinkish or red, and they experience burning, discomfort or foreign body sensation in addition to severe tearing, he said.

Because the meibomian glands are not manufacturing adequate oil component for the tear film, tears move from the surface of the eye and pool at the edge of the lower eyelid, Dr. Ng said. As a result, patients’ eyes appear wet and they constantly seem to be crying.

“(Patients) often complain of looking through water, yet they also complain of irritation because of the dryness of the upper part of the cornea because the tears are at the bottom,” Dr. Ng said.

He said he tells patients to use warm compresses and lid scrubs to treat the blepharitis and plugged tear glands. A combination steroid-antibiotic ointment is also prescribed for application to the lashes at night to eliminate bacterial infection.

Mark R. Levine, MD, FACS, Ocular Surgery News Oculoplastic and Reconstructive Surgery Section Editor, said in a telephone interview that he tells his acne rosacea patients to take flaxseed oil capsules, which contain omega-3 and omega-6 fatty acids. Both fatty acids are components in the manufacturing of prostaglandins, which help moderate inflammation, he said. Omega-3 fatty acids are anti-inflammatory and can be helpful when used in combination with an antibiotic at night, he said. An antibiotic steroid ointment at bedtime is beneficial, he said.

If the patient’s condition worsens, a derivative of tetracycline such as doxycycline can be given twice a day to control the bacteria, Dr. Levine said.

Patient with basal cell carcinoma, the most common cancerous skin lesion. When caught early, the lesion is easily cured through incision.

Patient with a noncancerous skin lesion, verruca vulgaris, or wart. Warts are caused by viruses in the human papillomavirus family. Images: Myint S

Atopic dermatitis

Atopic dermatitis, or eczema, is a chronic inflammatory skin condition marked by allergic reactions, Dr. Ng said. It occurs when a damaged layer of the epidermis allows irritants to affect the skin more intensely than usual, he said. Patients experience a waxing and waning of the inflammation and irritation of their skin, including symptoms such as weeping, cracking and crusting, Dr. Ng said.

Ocular symptoms of atopic dermatitis most commonly affect the upper eyelid, according to Dr. Ng. Patients develop dry, thickened skin and often lose their eyebrows and eyelashes from excessive rubbing. An extra fold of skin, called an atopic pleat, can develop under the eye, he said. Women are slightly more likely to have the disorder, and it is often diagnosed in childhood before the age of 5 years.

Patients with atopic dermatitis can develop keratoconus, conjunctival and corneal scarring, and mucous discharge. Dr. Ng said treatment, including steroids and antihistamines, aims to control allergic reactions to triggers such as mites, pollen, food and environmental irritants. He said treatment should be coordinated with the patient’s dermatologist.

Other dermatitis disorders that have ocular manifestations include contact eczema and allergic contact eczema, Dr. Levine said. He said it is often difficult to pinpoint the cause of contact eczemas, including eczematoid dermatitis, necessitating a close working relationship with the patient’s dermatologist.

Eczematoid dermatitis is marked by scaliness of the eyelids in the periorbital area that feels like atopic dermatitis, Dr. Levine said. The most common causes are exposure to hair sprays, nail polish, perfume and facial products that cause allergic reactions. It can often be treated with a steroid cream, according to Dr. Levine.

Lid lesions

Shoib Myint

Ocular skin lesions, noncancerous or cancerous, most often affect the lower eyelid margin, said Shoib Myint, DO, FACS, in a telephone interview with OSN. Common noncancerous lesions include squamous papilloma, seborrheic keratosis, epidermal inclusion cysts, or chalazia (sty). Nevi are also common in both children and adults, with an appearance resembling a dark spot, Dr. Myint said.

The most common skin cancer of the eyelid is basal cell carcinoma, followed by squamous cell carcinoma, sebaceous gland carcinoma and melanoma, according to Dr. Levine. Basal cell carcinoma affects 800,000 Americans each year, while the more serious squamous cell carcinoma affects about 200,000 Americans a year. Older men with fair complexions and an inability to tan are at a higher risk, he said.

“If you catch basal cell early and excise them, they’re curable,” Dr. Myint said. “An infiltrative lesion like squamous cell carcinoma is probably 40 times less common than basal cell, but it’s much more aggressive. When you see those, you have to be very aggressive in your treatment.”

Dr. Myint occasionally treats sebaceous carcinoma of the eyelid. He said the lesion is “dangerous” because of the possibility of systemic involvement, including organ and lymph node problems. Patients with sebaceous gland carcinomas have chronic styes that keep returning months after they are first treated, he said.

“You have to be really suspicious for squamous gland carcinoma,” Dr. Myint said.

He excises lesions, sends them out for histology and closes the lid. He treats each lesion on a case-by-case basis, excising more if necessary, based on the section results.

Patients are placed on topical antibiotics, he said. If their lesion was basal or squamous and has been excised, they have follow-up visits with their primary care physician and dermatologist. For a melanoma, lymphoma lesion or sebaceous carcinoma that is extending, patients are required to be evaluated by their family practitioner to search for systemic involvement, he said.

Eyelid of a patient with contact dermatitis, a form of eczema that is often caused by contact with products that induce several allergic reactions.	Facial features and excessive tearing of patient with acne rosacea, a chronic inflammatory condition. The meibomian glands in the eyelid, which produce the oil portion of the tears, are affected in the disorder, causing dilated vessels and flushing on both the face and eyelid margins.
Patient with reddened eyelids from atopic dermatitis, or eczema. The chronic inflammatory skin condition is caused by allergic reactions. It occurs when a damaged layer of the epidermis allows easier irritation of the skin.	Patient with irritated facial skin and excessive tearing caused by contact dermatitis. The disorder is marked by “waxing and waning” of inflamed and irritated skin, including symptoms such as weeping, cracking and crusting. Images: Ng JD

Ocular cicatricial pemphigoid

Ocular cicatricial pemphigoid is a relatively rare but “devastating” autoimmune disease that causes autoantibodies to bind to conjunctival basement membranes, leading to eventual blindness, Dr. Levine said. It causes scarring changes in the subconjunctiva, which induces ocular symptoms including dry eyes, symblepharon and cicatricial entropion. The symptoms can cause corneal damage and lead to cornea ulcerations and blindness, Dr. Levine said. Lashes will also turn against the cornea, he said.

“When the patient comes in to see you and you see the tear film has decreased, the lashes are rubbing against the cornea, and when you pull down the lid, you see that the fornix has been scarred — you think of cicatricial pemphigoid,” he said.

Similar symptoms can also be caused by pseudopemphigoid, a disorder often brought on by medications such as beta blockers, Phospholine iodide and epinephrine drugs. Dr. Levine said that the disease is rare, but he occasionally encounters it and works closely with dermatologists to ensure that patients have no systemic problems.

Women are at increased risk of ocular cicatricial pemphigoid, and onset of symptoms is typically between 50 and 60 years. Race is not considered a factor.

A study published in 1999 in Ophthalmology by Eric D. Donnenfeld, MD, and colleagues found that subconjunctival mitomycin C appeared to be effective in preventing the progression of cicatrization and erythema associated with the disease, with less damaging side effects than typically prescribed immunosuppressive agents including cyclophosphamide, azathioprine, methotrexate and diaminodiphenylsulfone.

For Your Information:

• Mark R. Levine, MD, FACS, can be reached at University Suburban Health Center, 1611 South Green Road, Suite 306A, South Euclid, OH 44121; 216-291-9770; fax: 216-291-0550.
• Shoib Myint, DO, FACS, can be reached at Consultants in Ophthalmic Plastic Surgery, 29201 Telegraph Road, Suite 305, Southfield, MI 48034; 248-357-5100; fax: 248-746-0683.
• John D. Ng, MD, FACS, can be reached at Oregon Health & Science University, Ophthalmic Facial Plastics Division, Casey Eye Institute, 3375 SW Terwilliger Blvd., Portland, OR 97239; 503-494-3010.

Reference:

• Donnenfeld ED, Perry HD, et al. Subconjunctival mitomycin C for the treatment of ocular cicatricial pemphigoid. Ophthalmology. 1999;106(1):72-78.

• Erin L. Boyle is an OSN Staff Writer who covers all aspects of ophthalmology.