Treatment Plan

Managing Eyelid and Periocular Contact Dermatitis

By William L. Miller, OD, MS, PHD, FAAO

Contact dermatitis is a subset of the family of eczematous skin diseases that can affect the periorbital and eyelid skin. The two main categories are allergic and irritative. Its cause(s) can be difficult to ascertain. In some cases, episodic or long-term medical therapy may be warranted, with additional recalcitrant cases necessitating a referral to an oculoplastic ophthalmologist or dermatologist.

Causes of Contact Dermatitis

The eyelid is particularly sensitive given that the skin of the region has only one-quarter the thickness of elsewhere on the body. This allows for easier penetration of allergens, and in some patients may be the only site of involvement (Amin and Belsito, 2006). The two-step process of initiation requires a sensitization followed by a re-exposure that elicits the inflammatory response.

Often the culprits are agents that come into contact with the eyelid skin, most notably certain metals such as nickel along with cosmetics used on the eyelid margin and eyelid skin. In addition, preservatives and surfactants in shampoos can be another common cause. Topical medications such as neomycin and preservatives used in topical ophthalmic drugs (glaucoma), face washes, hand scrubs, and cosmetics may also be implicated. To tease out the actual cause, especially for recurrent or recalcitrant cases, patch testing may be necessary to successfully identify the allergen.

Making a Diagnosis

The hallmark signs and symptoms of dermatitis include red, irritated, and scaly skin with varying levels of pruritis. The affected areas may be patchy or confluent.

First take a thorough history focusing on any changes in the daily routine regarding substances that could have come into contact with the eyelid or periorbital skin. Make sure to ask about hobbies or occupational pursuits. A thorough examination of the area is necessary both macroscopically and with a biomicroscope. Pay particular attention to a patient’s upper retracted eyelid, as this can be an ideal spot for dermatitis due to its intertriginous location.

Managing Contact Dermatitis

The first step in managing contact dermatitis is avoiding the offending agent. This may not be possible or known early in the dermatitis cycle. Discourage patients from trying to hide excoriated areas with cosmetic products.

Evaluate what treatment has already been self-initiated to guide your specific management strategy. Emollients, cold compresses, topical antipruritics, and, in some cases, oral antihistamines may help relieve symptoms.

Depending on the initial severity, a two- to four-week course of topical steroids or topical calcineurin inhibitors (TCIs) might be indicated. A low- to mid-potency topical steroid such as betamethasone (q.d., b.i.d.), alclometazone (b.i.d., t.i.d.), or desonide (b.i.d., t.i.d.) can be applied, but be careful of long-term use because of possible side effects.

To avoid side effects, some practitioners prescribe topical medications such as TCIs, which may work well for the thin skin of the eyelid and periorbital areas (Fleischer, 1999; Sengoku et al, 1999). This would include tacrolimus (Protopic ung 0.03% or 0.1%, b.i.d.) and pimecrolimus (Elidel 1% cream, b.i.d.). These medications carry a black box warning for rare malignancies, and should not be used in patients under the age of 2; the 0.03% concentration should not be used in patients 15 and under. CLS

For references, please visit www.clspectrum.com/references.asp and click on document #218.

Dr. Miller is an associate professor and chair of the Clinical Sciences Department at the University of Houston College of Optometry. He is a consultant or advisor to Alcon and Vistakon and has received research funding from Alcon and CooperVision, and lecture or authorship honoraria from Alcon and B+L. You can reach him at wmiller@uh.edu.