BLOG: Dermatitis of the eyelids – one itch and scratch too many

Read more blog posts from Mark R. Levine, MD

If there is any one condition I dread seeing, it is dermatitis of the eyelids. It is easy to treat with cortisone ointment – unless it comes back. Then what?

The condition is a challenge for the dermatologist also.

I have enough knowledge to help a good percentage of patients, it is the others who are the challenge. Short of saying refer all these patients to the dermatologist, I will offer my two cents on the subject.

The clinical changes associated with eyelid dermatitis are erythema associated with some degree of swelling, dryness and pruritus. The involved skin may show acute or chronic changes ranging from water filled vesicles to lichenified skin. Most of what I see is scaling and lichenification.

The most common reported causes of eyelid dermatitis is allergic contact dermatitis. Irritant contact dermatitis and atopic eczema are the next most common causes. Dermatitis occurs mostly in women. Allergic contact dermatitis is a delayed hypersensitivity reaction mediated by the cellular immune system against specific allergens. These allergens are chemicals that are common in everyday products and in prescription products. They often are added to products for enhancing texture, efficiency, shelf life or patient satisfaction.

These chemicals also can cause irritant contact dermatitis which is not an immunologically based memory reaction. The most common allergens implicated in pure eyelid dermatitis are gold, fragrances, Balsam of Peru and nickel sulfate. The majority of cases occur from the use of cosmetic products such as moisturizers and lotions. Fragrances and preservatives are the most common specific allergens in these categories. However, nail polish, hair sprays, soaps and colognes also must be considered. Other allergens commonly implicated in eyelid dermatitis include Benzalkonium chloride and neomycin sulfate, which we are all familiar with.

I would like to discuss a little more about specific allergens:

Gold. The primary source of exposure to gold is from jewelry. In pure eyelid dermatitis, the removal and avoidance of all jewelry that contains gold is recommended.
Fragrance, like gold, continues to be a major contact allergen and is a common source of allergy in pure eyelid dermatitis. Fragrance avoidance does not just encompass the removal of perfumes and colognes. Fragrance exposure is widespread and sometimes unavoidable. Fragrance is added to many substances that we use in our daily lives such as soap, shampoos, detergents, fabric softeners, household cleaners, etc. Even though the fragrances are not directly applied to the eyelids, hand transfer and airborne exposure can occur.
Balsam of Peru is a fragrant liquid resin that, like fragrances, may be found in unexpected places. It may be added to products for fragrance, flavoring or as an antibacterial agent. It may be found in a wide range of products including perfumes, medicinal creams, ointments, air fresheners, etc.
Nickel is one of the most common allergens in the general dermatitis population and it is sometimes incorporated in glasses with metal frames or parts. It can also be in eyelash curlers and eye makeup. Indirect exposure with high incidences of hand transfer will account for exposure to nickel. This may be from items such as metal door handles, restroom faucets, car keys, zippers, buttons, etc. Avoidance of contact between the hand and the face and the eyelid area is critical for complete allergen avoidance.
Finally, we are all aware of Benzalkonium chloride. Because of its involvement in ophthalmologic preparations, this is an obvious cause.

The differential diagnosis for eyelid dermatitis is extensive. This ranges fro seborrheic dermatitis, psoriasis, rosacea, dermatomycosis, dermatomyositis, cutaneous T-cell lymphoma and squamous and basal cell carcinoma.

When evaluating these patients, I try to ask some basic questions:

1) Have you used any new products on the eyelids or general face and scalp area?

2) Do you use any prescription, natural or over-the-counter products on your face?

3) When did you last buy new makeup?

4) Have you recently traveled?

My generalized approach to patient management prior to patch testing is to stop all soaps, hairsprays, colognes, eye liner, nail polish, etc. for a couple of weeks. I suggest that the patient uses non-soap cleaners without any fragrances or preservatives. I will then treat the patient with cortisone ointment three to four times a day for a week and reassess.

At that time, if the dermatitis is gone, I suggest to the patient that they add one fragrance or makeup at a time over the course of a few days to see whether any of the products will cause a recurrent dermatitis. I always tell them to wash their hands prior to touching their lids or adding eye and face makeup. If patients are unhappy with that approach, I try to tell them that it is necessary to reduce allergens/irritant exposure and contact.

Much of the time this is all that is necessary to find out the inciting agent being an allergic contact dermatitis or an irritant contact dermatitis.

Despite all these measures, if the dermatitis reoccurs or does not clear up, I generally will go to a small skin biopsy in hopes that it will give me information such as an early in situ squamous cell carcinoma, basal cell carcinoma, psoriasis or a collagen vascular disease. If my biopsy does not point me in the right direction, I am then left with doing patch testing by the dermatologists in hopes of getting clues as to resolution of the problem.