Eyelid dermatitis refers to a contact dermatitis, allergic or irritant, affecting the eyelids. It’s a very common problem and the commonest skin disease of the eyelids.
The eyelids are very prone to contact dermatitis due to the thinness of the skin. They’re only a quarter of the thickness of the skin on the rest of the face. There’s a relatively high level of percutaneous absorption. Also, they are frequently touched and rubbed inadvertently by contaminated hands and fingers. Due to the greater absorption on the eyelids, they are more likely to be affected, whereas the source areas can remain disease-free. Although irritant contact dermatitis (ICD) is the most common form of contact dermatitis, allergic contact dermatitis (ACD) is the predominant source of eyelid dermatitis.
The hallmark of eyelid dermatitis is an acute eruption of poorly demarcated erythema with a papulovesicular eruption and swelling accompanied by itching. ICD can be more dry, with fine scaling, and often more burning than itching.
The distribution of ACD is often the most important clue to the diagnosis of the disease, as it typically affects the area of greatest exposure to the offending allergen. However, in eyelid dermatitis, areas from which the allergen was transferred are often spared.
Sources of eyelid allergic contact dermatitis
A careful history, including detailing all possible allergen contacts, and physical examination are key to solving the probable cause of a patient’s eyelid dermatitis (see Table 1). Most patients use a variety of nail products, hair products and cosmetics. Nail polish can be transferred to the eyes when touching the face. Glues in artificial nails can be transferred in a similar fashion. Hair dyes, bleaching agents, perfumed hair sprays and shampoos may affect the eyelids without any associated scalp or forehead dermatitis. Interestingly, cosmetics applied to the hair, face or fingernails are more commonly implicated in eyelid ACD than those applied to the eyelids themselves.
Ophthalmic medications, such as topical antibiotics and beta-blockers, should also be reviewed as potential allergens. A good clue is that dermatitis can also be present below the nares
in addition to the eyelids, suggesting transfer of allergen through the nasolacrimal duct. Also consider a possible contact allergy to topical steroids, either the steroid itself or the vehicle.
Nickel is a very common cause of ACD, with a prevalence in the general population of roughly 15%. Patients can develop eyelid dermatitis from nickel-plated eyelash curlers, nail files and tweezers.
Plants are another source of eyelid ACD to consider. Poison ivy, poison oak and poison sumac can cause marked swelling of the eyelids with minimum involvement of the face.
Another source of eyelid dermatitis is hand transfer. This is commonly seen in poison ivy dermatitis and may be seen in persons handling rubber, metals and other materials. Rubber in makeup sponges and eyelash curlers may also affect the eyelids.
Airborne allergens include pollens, animal hairs, dust and any volatile agent such as household sprays, insecticides and occupational chemicals. The phosphorous sesquisulfide in “strike anywhere” matches can also produce eyelid dermatitis by an airborne route.
Other less common causes of eyelid dermatitis include sensitization to fragrances or formaldehyde in facial tissues. Newsprint and carbon paper may produce eyelid dermatitis, through sensitization to formaldehyde.
There are many conditions that can produce redness of the eyelids (see Table 2). Irritant contact dermatitis is mainly a diagnosis of exclusion. Atopic dermatitis (AD) often affects the eyes in adults. ACD usually affects the upper eyelids while AD frequently causes eyelid dermatitis involving both the upper and lower eyelids. AD may itself be a risk factor for ACD. Seborrheic dermatitis and rosacea are often seen in other areas as well. Psoriasis may be accompanied by lesions in other areas, nail changes and/or a positive family history. Dermatomyositis can produce a heliotrope-like eruption (deep purple) of the upper eyelid with swelling, and other findings would be expected.
Investigations and management
The diagnosis of eyelid dermatitis is usually made from a detailed history, physical findings and patch testing. Patients should be referred to a dermatologist for consideration of patch testing.
Patch testing, when done properly, can confirm the presence of an allergic contact dermatitis. Purified potential allergens of known concentrations are placed under non-allergenic aluminum discs (Finn chambers) and held in place with tape. Patch testing is usually done on a patient’s back, provided the back is clear of any dermatitis. Patients mustn’t get the area wet during the testing. The patient returns to the office in 48 hours, the chambers are removed and early readings are done. The patient returns for the final read at 5-7 days. The final delayed read is crucial, as many allergens will be missed or mistaken for positives at 48 hours. A positive reaction has various grades depending on the amount of erythema and vesicles. Tests must be interpreted carefully,
as patch testing can show many false negatives and false positives.
If patch testing, after proper interpretation, suggests a possible allergen, it should be completely eliminated from a patient’s routine. Sometimes this is difficult, but many resources are available to counsel patients on product selection. Elimination can result in rapid clearing.
Patients should also be offered topical corticosteroid therapy. Mild potency steroids can be used safely for short periods around the eyes and are effective. Topical calcineurin inhibitors such as pimecrolimus or tacrolimus can be used to decrease inflammation without the side effects of topical steroids. Be warned, however, they can sometimes produce burning on application.
John Kraft, MD, is in his third year of the Dermatology Residency Program at the University of Toronto.
Table 2 - Differential diagnosis of eyelid dermatitis