Management of itchy, swollen, red eyelids can be a challenging diagnostic and therapeutic task for an ophthalmologist. Causes range from severe blepharitis to contact dermatitis (with a slew of possible culprits—from topical medications to environmental irritants). Below is a review of a general approach to the patient with eyelid dermatitis, and how to best sort out treatment options depending on underlying cause and severity.
The eyelids have a thin epidermis, a small amount of fat, and high vascular density—all qualities that make them more sensitive to allergens and irritants (e.g., shampoo can cause eyelid dermatitis while the scalp may remain relatively unaffected).1-3 Eyelid dermatitis may be bilateral, unilateral, may involve the upper and/or lower lids, or both. In addition, there may also be features of thickening from chronic rubbing and scratching.1-4 The eyelid skin may appear fissured; crusting may occur on the eyelashes.5 Approximately 25% of patients with eyelid dermatitis may have associated conjunctivitis; dermatitis may also be present elsewhere—including the neck, face, and periauricular skin.1-8 There are several different kinds of eyelid dermatitis; the most common kinds will be covered below.
Allergic contact dermatitis
Allergic eyelid dermatitis is the most common cause of eyelid dermatitis (~50% of cases) and often presents with edema, erythema, and scaling of the eyelid skin, as well as symptoms of burning and itching.2-4,8,9 The majority of patients with allergic contact eyelid dermatitis are female (80-90%).2-4,8,9 In addition, the majority of periocular dermatitis is not from direct ocular exposure, but rather indirect extraocular contact!
Preservatives: Preservatives such as benzalkonium chloride (BAK), which is very widely used in ophthalmic therapeutics, is also a well-known skin irritant.2-4,8,9 BAK can be found in commonly used eye drops, such as atropine, tropicamide, pilocarpine, timolol, proparacaine, phenylephrine, as well as commercially prepared artificial tears.2-4,8,9 If an allergy to BAK has been identified or is suspected, patients should be prescribed preservative-free formulations.
Cosmetics: Incidence of contact dermatitis due to cosmetics may be as high as 30%. This is more often caused by indirect contact with cosmetics from the face, fingernails, or hair.1,2,9 Cocamidopropyl betaine (CAPB) is a common allergen found in shampoos, soap, makeup removers, and eye cosmetics. In addition, makeup applicators and brushes may also lead to contact dermatitis (as well as their respective cleansers, if not thoroughly rinsed from the brushes).2-4,8,9
Nails: Nails fall under their own category as a source of cosmetic-related dermatitis as many nail treatments, lacquers and polishes may induce a spectrum of eyelid dermatitis.1,2,9 Nail polish, methacrylate, and cyanoacrylates used in artificial nails are all common irritants.1,2,9 It is important to note that these may cause eyelid or periocular dermatitis WITHOUT changes to the patient’s nail beds!2-4,8,9
Metals: Nickel in particular is a very common allergen found in mascaras, eyelash curlers, eye shadow, eyebrow pencils, and even some contact lens cleaning solutions.1,2,4,9 Direct contact with nickel can cause contact dermatitis, but hand transfer from a metal nail file, occupational exposure, or jewelry worn on the hands or wrist can also cause eyelid dermatitis.1,2,4,9
Hair Dye: A common chemical allergen in hair dye is a compound called paraphenylenediamine (PPD).2-5,8,9 PPD can also be found in textile/fur dyes, henna tattoos, photography film, black rubber, oils, and gasoline.2-5,8,9 Occupational allergy can be elicited from hairdressers and with those in contact with printing inks/films.2-5,8,9 As with the aforementioned allergens, the presentation may be localized to upper eyelid dermatitis with/without scalp, face, or body involvement.
Airborne: Airborne contact dermatitis is due to exposure to antigen or irritant particles suspended in the air.1-3,5,6 This includes plant and wood antigens, aerosolized plastics, rubber, glues, and agricultural dusts.1-3,5,6 Plants of the Compositae family (e.g, ragweed, sunflower, chrysanthemum) are among the most frequent cases of airborne contact dermatitis of the eyelids.1-3,5,6
Protein: Protein contact dermatitis is IgE-mediated and is due to sensitization to plant and/or animal proteins.1-3,5,6 These include foods, pollen, animal hair and latex.1-3,5,6
When approaching the patient with allergic contact eyelid dermatitis, it is helpful to remember to NOT limit the suspected allergens to those in direct contact with the eyes, as the majority of causes for periocular dermatitis are extraocular contacts. As with most evaluations, obtaining a detailed history is key, including known history of allergies, all recently used cosmetics, cleansers, ophthalmic solutions, occupational and leisure exposures. It may also be helpful to have the patient bring in/take photos of solutions and creams applied to the face and body to help identify the causal agent. If history and exam do not elicit a particular allergen, and treatment attempts are unsuccessful, patch testing can be considered with the assistance of a dermatologist and/or allergist.1-3,5,6 Skin biopsy is generally not indicated for the diagnosis of eyelid dermatitis; histopathologic exam here typically shows nonspecific changes common to most types of eczematous dermatitis and therefore may not help identify a specific cause.1-3,5,6 That being said, if a patient is failing treatment, or if their condition is worsening, skin biopsy, in that case, may be performed to rule out connective tissue disease (e.g., dermatomyositis, mixed connective tissue disease).1-3,5,6
The key concept in treating eyelid dermatitis is identification and avoidance of the offending agent. Cool compresses can help provide symptomatic relief, and cautious use of topical steroids may be considered.1-3,5,6 Low potency topical steroids may be used for a period of 2-4 weeks; a steroid ‘holiday’ can be considered if the patient needs chronic treatment to avoid possible adverse effects of steroid use. It is important to educate patients that chronic corticosteroid use on the eyelid can be associated with skin atrophy, glaucoma, cataracts, and increased susceptibility to infection. In addition, long-term use of topical steroids on the eyelids can also lead to the development of periorbital dermatitis, a rosacea-like condition.1,6-9 Steroid-sparing agents such as tacrolimus 0.1% ointment or pimecrolimus cream may also be applied twice daily to the affected areas until there is clearance of the dermatitis.1,6-9
Atopy can be associated with atopic eyelid dermatitis and may present in childhood. It may also be associated with asthma and seasonal allergies.1-3,8,10,11 Irritants, even if mild in nature, may also play a role in the development and potentiation of eyelid dermatitis in patients with atopic disease. In this condition, the upper eyelids may appear scaly and fissured; there may be extra skin folds noted under the lower lid and dark circles under the eyes from chronic rubbing.1-3,8,10,11 Atopic eyelid dermatitis may be chronic and flare with seasonal/environmental exposure to allergens.1-3,8,10,11
Management of atopic dermatitis is similar to allergic contact dermatitis—avoidance of offending agents and judicious use of topical steroid preparations.1-3,8,10,11 In addition, it may be necessary to utilize systemic medications for allergy, and co-management with an allergist may prove especially helpful for these patients.
Seborrheic dermatitis is a chronic, relapsing form of eyelid dermatitis that also has a predilection for the scalp, chest, nasolabial creases, and intertriginous areas.1-4,8 It may also commonly involve the eyelid margin (seborrheic blepharitis).1-4,8 This is a less common form of eyelid dermatitis and can coexist with blepharitis and meibomian gland dysfunction.1-4,8 Seborrheic dermatitis of the eyelids may appear scaly and waxier than contact or atopic dermatitis. Here, itching is less common; patients may have more skin flaking and burning.1-4,8
Patients with seborrheic eyelid dermatitis usually present with greasy scaling of the eyelid skin and eyelid margin.1-4,8 Skin examination of sebaceous-rich areas of skin with concomitant seborrheic dermatitis can help support the diagnosis.1-4,8 It may be necessary for some patients to rule out fungal infection of the skin, as tinea faciei can rarely present with similar findings.1-4,8 Seborrheic eyelid dermatitis is generally a gradual, indolent condition, but if a patient presents with acute, severe onset of disease, HIV should be considered and appropriate lab tests ordered.1-4,8,12 Seborrheic dermatitis has a much higher incidence (some reports up to 45%) in HIV+ patients versus those without the disease.1-4,8,12
Eyelid hygiene and cleansing are key in controlling seborrheic dermatitis to help remove excess oils.1-4,8 Patients must be educated that good eyelid hygiene must be a lifelong commitment! Application of warm compresses may alleviate signs and symptoms of seborrheic blepharitis as well.1-4,8 Topical steroid may be used judiciously to relieve irritation and redness if present.1-4,8,11 In severe cases, tacrolimus ointment may be employed if recalcitrant to topical steroid and eyelid hygiene techniques.1-4,8,11
Rosacea is chronic inflammatory disorder that can affect the eyes and face. Typical patients are female, 30-60 years old, and demonstrate characteristic facial flushing worsened by stress, spicy food, heat, or alcohol, as well as red, acne-like lesions.1-4,6,8 Symptoms of ocular rosacea may be nonspecific and may include burning, stinging, and itching.1-4,6,8 Many patients with ocular rosacea may have significant sensitivity to a wide range of topical products and sun exposure.1-4,6,8 In addition, symptoms of dry eye (burning, grittiness, foreign body sensation) in conjunction with swelling, itching, and scaling of the eyelids may be seen.1-4,6,8
Patients with ocular rosacea may present with facial/eyelid redness as well as conjunctival injection.1-4,6,8 The eyelids may be erythematous, scaly, and edematous, with scaling of the eyelid margin and eyelid thickening.1-4,6,8 Telangiectasia may be present on the eyelid margin as well as the face (chin, cheeks, nose, forehead).1-4,6,8
As with seborrheic eyelid dermatitis, eyelid hygiene is key to the treatment of ocular rosacea.1-4,6,8 It is important for patients to be aware of systemic triggers of inflammation—stress, excess sugar, and spicy foods may make the condition worse. In addition, Demodex infestation of the eyelids/eyelashes has been associated with ocular rosacea.1-4,6,8 If this condition is concomitantly diagnosed, treatment with commercial wipes, tea tree oil, and in severe conditions, topical ivermectin may be very helpful. In addition, oral tetracyclines (e.g., doxycycline 100-200mg daily for at least 6 weeks then tapering to a low dose regimen) can prove very helpful in treatment of this condition.1-4,6,8 Antibiotic precautions should be taken (probiotics, gastrointestinal prophylaxis if necessary) due to the long treatment course here. Topical macrolide (e.g., erythromycin, azithromycin) ointment may also be applied to the eyelids 1-3 times per day for relief.1-4,6,8 In severe cases, topical steroids may also be used here judiciously.
Dermatitis in the periocular area can be frustrating to treat—for both the patient and physician. Lack of recognition of clinical signs may lead to a delay in diagnosis and therefore treatment. Once the diagnosis is made, attention should be focused on all entities that may be exacerbating the condition. Avoidance of the offending agent(s) and topical anti-inflammatories are the mainstays of treatment.
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- Guin JD. Eyelid dermatitis: Experience in 203 cases. J Am Acad Dermatol 2002;47:755-65
- Ockenfels HM, Seemann U, Goos M. Contact allergy in patients with periorbital eczema: An analysis of allergens. Data recorded by the Information Network of the Departments of Dermatology. Dermatology 1997;195:119-24
- Zug KA, Palay DA, Rock B. Dermatologic diagnosis and treatment of itchy red eyelids. Survey of Ophthalmology 1996;40:293-306
- Graves JE, Brodell RT. Erythematous scaling eyelids: Patient history, exposure to allergens and irritants are keys to diagnosis. Postgrad Med 2005;117:43-5
- Wolf R, Orion E, Tüzün Y. Periorbital (eyelid) dermatides. Clin Dermatol. 2014 Jan-Feb;32(1):131-40. doi: 10.1016/j.clindermatol.2013.05.035. PMID: 24314387.
- George C, Walsh S. Periocular rash. BMJ. 2018 Dec 21;363:k5098. doi: 10.1136/bmj.k5098. PMID: 30578243.
- Amin KA, Belsito DV. The aetiology of eyelid dermatitis: a 10-year retrospective analysis. Contact Dermatitis. 2006 Nov;55(5):280-5. doi: 10.1111/j.1600-0536.2006.00927.x. PMID: 17026693.
- Gilissen L, De Decker L, Hulshagen T, Goossens A. Allergic contact dermatitis caused by topical ophthalmic medications: Keep an eye on it! Contact Dermatitis. 2019 May;80(5):291-297. doi: 10.1111/cod.13209. Epub 2019 Mar 19. PMID: 30629291.
- Blanc S, Bourrier T, Albertini M, Chiaverini C, Giovannini-Chami L. Dennie-Morgan fold plus dark circles: suspect atopy at first sight. J Pediatr. 2015 Jun;166(6):1541. doi: 10.1016/j.jpeds.2015.03.033. Epub 2015 Apr 15. PMID: 25890677.
- Nivenius E, van der Ploeg I, Jung K, Chryssanthou E, van Hage M, Montan PG. Tacrolimus ointment vs steroid ointment for eyelid dermatitis in patients with atopic keratoconjunctivitis. Eye (Lond). 2007 Jul;21(7):968-75. doi: 10.1038/sj.eye.6702367. Epub 2006 May 5. PMID: 16680103.
- Maurer TA. Dermatologic manifestations of HIV infection. Top HIV Med. 2005 Dec-2006 Jan;13(5):149-54. PMID: 16377853.