Eyelid dermatitis (eczema)

INTRODUCTION — Eyelid dermatitis, also known as periocular dermatitis or periorbital dermatitis, presents with a scaly, erythematous eruption of the upper and/or lower eyelids and, possibly, the periorbital area [1,2]. Patients often report symptoms of itching, burning, and stinging. Swelling may be present. Eyelid dermatitis may be caused by contact with irritants or allergens, or it can be a manifestation of an underlying skin disease, such as atopic dermatitis or seborrheic dermatitis. A periorbital dermatitis may also be a manifestation of rosacea or periorificial (perioral) dermatitis.

This topic will discuss the clinical manifestations, differential diagnosis, evaluation, and treatment of the most common types of eyelid dermatitis. Blepharitis, a chronic inflammation of the eyelid margin associated with eye irritation, is discussed separately. Rosacea and periorificial dermatitis are also discussed separately.

●(See "Blepharitis".)

●(See "Rosacea: Pathogenesis, clinical features, and diagnosis".)

●(See "Perioral (periorificial) dermatitis".)

EPIDEMIOLOGY — Eyelid dermatitis is usually seen in adults and teens and is less common in children, unless associated with atopic dermatitis (AD). The exact prevalence of eyelid dermatitis in the general population is unknown, but it is commonly encountered in clinical practice. Both males and females can manifest eyelid dermatitis, but females greatly outnumber males in most patch test studies of patients presenting with eyelid dermatitis [3-9].

Allergic contact dermatitis (ACD) is the most common type of eyelid dermatitis, accounting for approximately 50 percent of cases, followed by irritant contact dermatitis (ICD) and atopic eyelid dermatitis [3,4,10,11]:

●In a retrospective review of 2332 patients with eyelid dermatitis referred for patch testing, 43 percent had ACD, 17 percent had ICD, 15 percent had unspecified dermatitis, 13 percent had AD, and 4.5 percent had seborrheic dermatitis [9]. Patients with head and neck involvement in addition to eyelid dermatitis were more likely to have ACD than patients with eyelid dermatitis alone (53.5 versus 43 percent).

●A 10-year retrospective review from a single institution of 105 patch test patients with eyelid dermatitis found that 43.8 percent of patients had ACD, 38 percent had seborrheic dermatitis, and 7.6 percent had ICD [4].

●A study of 362 females with eyelid dermatitis found that 50.1 percent had ACD, 20.9 percent had ICD, 13.5 percent had AD, 6.5 percent had an unspecified dermatitis, 6.3 percent had seborrheic dermatitis, and 2.9 percent were diagnosed with psoriasis [10]. Involvement of all four lids was strongly associated with ACD.

●A study of 609 patients with periorbital dermatitis who underwent patch testing found that 52 percent had underlying ACD with common allergens, including nickel, benzoyl peroxide, fragrances, and antimicrobials [3]. Allergic eyelid dermatitis patients had an increased rate of allergies to topical antimicrobials and antibiotics, which may reflect exposure to topical eye medicaments [3].

ETIOLOGY — The cause of eyelid dermatitis is often multifactorial. It may result from contact with irritants or allergens, or it can be a manifestation of an underlying skin disease, such as atopic dermatitis (AD) or seborrheic dermatitis [1].

Contact dermatitis — The eyelids are a sensitive site due to the thinness of the skin and the potential increased penetration of allergens and irritants. Frequently, eyelids may be the only site affected by contact dermatitis. For example, eyelid dermatitis may be the only manifestation of contact dermatitis to hair care products, in the absence of a coexisting eruption on the scalp. Nail products and other allergens may be transported from the hand to the eyelid area and may cause isolated eyelid dermatitis in the absence of hand dermatitis.

Allergic contact dermatitis — Allergens found to cause allergic contact dermatitis (ACD) on the eyelids include metals (eg, nickel, gold), fragrances, preservatives, and topical antibiotics [4-9]:

●In a study of 3955 patients with either eyelid dermatitis alone or eyelid and head/neck dermatitis referred for patch testing, the most common allergens found were nickel, fragrance mix 1, methylisothiazolinone, gold, and balsam of Peru [9]. Less common, but important, allergens seen in patients with eyelid dermatitis included carmine, shellac, benzalkonium chloride, and dimethylaminopropylamine.

●In one study of 1247 patients referred for patch testing, including 266 patients with periorbital dermatitis and 981 without periorbital dermatitis, the sensitization pattern was not different in the two groups, with nickel and fragrance mix being the most frequently involved sensitizers [7].

●In a retrospective study of 215 patients with periorbital dermatitis who underwent patch testing, the allergen groups associated with the highest rates of positive reactions were, in decreasing order, metals (eg, nickel in eyewear, gold jewelry), shellac (a gloss or coating used in skin care products), preservatives (eg, benzalkonium chloride), topical antibiotics (neomycin, bacitracin), fragrances, acrylates (in artificial or gel nails), and surfactants (eg, in soaps and shampoos) [12].

●Fragrance is commonly found to cause allergic eyelid dermatitis. In a study of 100 patients with eyelid dermatitis who underwent patch testing, 42 were found to be positive to a fragrance or fragrance marker. However, 15 of the 42 patients (36 percent) only reacted to a fragrance chemical on a supplemental fragrance tray, suggesting that fragrance-allergic patients may be missed by only testing for fragrance screeners on a standard patch test tray [13].

●Gold remains another cause of eyelid dermatitis. Exposure to gold occurs from jewelry on the hands or ears and perhaps is worsened by concurrent use of mineral-based cosmetics or sunscreens. Gold was the most commonly relevant positive reaction in a study of 268 patients with eyelid ACD who had undergone patch testing [6].

●Nail polish, particularly those made from acrylates, can also cause ACD on the face and eyelids [14].

Topical ophthalmic preparations may cause irritant contact dermatitis (ICD) or ACD:

●In a study of 4779 European patients with periorbital dermatitis who underwent patch testing over a 10-year period, antibiotics (gentamicin, neomycin, kanamycin) in topical ophthalmic preparations were the leading group of allergens [5].

●A study of 118 patients with ACD due to topical ophthalmic preparations found that the active ingredient (antibiotics or steroids) was the culprit 59 percent of the time. The vehicle (wool alcohol, preservatives) was the source of ACD in 29 percent of patients, with 12 percent of patients reacting to both the active drug and a component of the vehicle [15].

Airborne contact dermatitis — Airborne contact dermatitis of the eyelids is caused by exposure to antigen or irritant particles suspended in air. These include plant antigens, wood allergens, plastics, rubber, glues, metal, industrial and agricultural dusts, pesticides, and drugs [1]. Plants of the Compositae family (eg, parthenium, ragweed, aster, sunflower, chrysanthemum, artichoke) are among the most frequent causes of airborne contact dermatitis of the eyelids.

Protein contact dermatitis — Protein contact dermatitis is an immunoglobulin E (IgE)-mediated ACD due to sensitization to plant or animal proteins [16]. These include foods, pollen, animal hair, and latex.

Irritant contact dermatitis — Irritants known to cause or exacerbate eyelid dermatitis include soaps, preservatives, and fragrances. The use of antiaging products on the face can cause eyelid dermatitis in the absence of other sites involved, even if the product is not being directly used on the eyelids. Patients with eyelid dermatitis should be specifically asked about the use of topical retinoid derivatives on the face.

Atopic dermatitis — Eyelid dermatitis may occur in patients with a history of childhood-onset atopic dermatitis (AD) and/or other atopic diseases, including asthma and seasonal allergies. Irritants often play a role in the development of eyelid dermatitis in patients with atopic disease. Additionally, patients with AD may develop superimposed ACD and protein contact dermatitis involving the eyelids.

Seborrheic dermatitis — Seborrheic dermatitis is a chronic, relapsing form of dermatitis that has a predilection for nasolabial creases, eyelids, ears, scalp, chest, and intertriginous sites. Less commonly, it may involve the eyelid skin and/or the eyelid margin (seborrheic blepharitis). In a series of 447 patients with eyelid dermatitis, 6 percent were diagnosed with seborrheic dermatitis [10]. (See "Seborrheic dermatitis in adolescents and adults" and "Blepharitis".)

CLINICAL MANIFESTATIONS — Eyelid dermatitis generally presents as an erythematous, scaly, pruritic rash on the upper and/or lower eyelids (picture 1A-D) [17,18]. Some patients may complain of burning and pain, and associated swelling may be present. Eyelid dermatitis can be unilateral or bilateral and may occur in isolation or be associated with dermatitis of other body sites. Dermatitis is bilateral in most cases but may be unilateral and affect the upper eyelids, lower eyelids, or both.

Clinical findings may vary according to the etiology. Pruritus is often a prominent symptom of allergic contact dermatitis (ACD), and there may be features of lichenification from chronic rubbing and scratching. Patients with eyelid irritant contact dermatitis (ICD) may have more symptoms of burning or pain and less pruritus.

Eyelids may appear fissured, and crusting may occur on the lashes. Approximately 25 percent of patients with eyelid contact dermatitis have an associated conjunctivitis [18]. Dermatitis is often present elsewhere on the body, including the face, neck, and periauricular skin.

However, atopic eyelid dermatitis and contact eyelid dermatitis can be clinically indistinguishable, and patch testing is often necessary for the correct diagnosis. Additionally, patients with atopic dermatitis (AD) may develop superimposed ACD. (See 'Patch testing' below.)

Atopic eyelid dermatitis often develops in teenage years and adulthood but may also occur in older individuals. Occasionally, it can be the only manifestation of AD. The upper eyelids may appear scaly and fissured (picture 2A-B). The so-called "allergic shiners" (symmetric, dark circles beneath the lower eyelid) and Dennie-Morgan lines (extra skin folds under the lower eyelid) are often present (picture 2C) [19]. (See "Atopic dermatitis (eczema): Pathogenesis, clinical manifestations, and diagnosis".)

Seborrheic dermatitis on the eyelids may appear scaly and waxier than contact dermatitis or AD (picture 2D); itching is less common than other symptoms, such as flaking or burning.

CLINICAL COURSE — Clinical course often varies with etiology. Eyelid dermatitis may wax and wane and sometimes exhibits seasonal variation. For example, eyelid dermatitis associated with underlying atopic dermatitis may be chronic and flare with seasons and exposure to environmental allergens. Patients may notice that airborne irritants, including plants, pollens, dust, and dander, may trigger or worsen the disease. Eyelid dermatitis may also flare with hay fever, allergic rhinitis, or conjunctivitis, possibly related to chronic tearing or mechanical rubbing. Occupational eyelid dermatitis may worsen with workplace exposures and improve with time off from work.

DIAGNOSIS

Clinical — The diagnosis of eyelid dermatitis is made in most cases clinically, based on the characteristic appearance of the eruption, associated symptoms, and clinical history. A full skin examination for other areas of dermatitis should be performed in all patients.

A careful clinical history may provide clues to the etiology. As an example, the presence of bilateral eyelid dermatitis, prominent itch, involvement of other sites on the face, lack of seasonal variation of symptoms, and a history of temporary or inadequate improvement with standard treatment suggest the diagnosis of allergic contact dermatitis (ACD). A careful history of exposure to potential allergens should be elicited in patients with suspected eyelid ACD. Patch testing may be needed to confirm the diagnosis. (See 'Patch testing' below.)

Atopic eyelid dermatitis is suspected in adolescents and young adults with a history of childhood-onset atopic dermatitis (AD) and/or other atopic diseases, including asthma and seasonal allergies. The presence of an associated flexural dermatitis supports the diagnosis. However, exposure to irritants or contact sensitization may have a role in the development of eyelid dermatitis in patients with atopic disease.

Patch testing — Atopic eyelid dermatitis and contact eyelid dermatitis can sometimes be clinically indistinguishable. Any patient with eyelid dermatitis requiring ongoing treatment beyond four to eight weeks should be strongly considered for patch testing to ensure the correct diagnosis. In a study of 401 patients with eyelid dermatitis who were patch tested, contact hypersensitivity was detected in 34 percent of patients; the most frequent sensitizers were nickel sulfate, fragrance mix, balsam of Peru, paraphenylenediamine, and thiomersal [20].

If patch testing is negative or positive reactions are deemed not to be relevant to the current dermatitis, the diagnosis of irritant contact dermatitis (ICD) should be considered. In a series of 609 patients with eyelid dermatitis, 21 percent had negative patch testing and were subsequently diagnosed with ICD [3]. (See "Clinical features and diagnosis of allergic contact dermatitis", section on 'Diagnosis' and "Patch testing".)

Skin biopsy — A skin biopsy is generally not helpful for the diagnosis of eyelid dermatitis. Histopathologic examination would show nonspecific changes that are common to all types of eczematous dermatoses (eg, spongiosis [epidermal edema], lymphohistiocytic infiltrate in the dermis) and, therefore, would not help identify the specific cause of eyelid dermatitis. However, a skin biopsy can be performed if the diagnosis is uncertain and, in particular, to rule out connective tissue disease and dermatomyositis. A biopsy showing interface dermatitis would suggest connective tissue disease and prompt further evaluation for autoimmune disease.

ASSOCIATED OCULAR DISEASE — Most patients with eyelid dermatitis do not have associated eye disease. However, patients with atopic dermatitis have an increased risk of comorbid eye diseases, including keratitis, conjunctivitis, and keratoconus [21]. A careful clinical examination for associated erythema, crusting, and blepharitis may prompt referral to an ophthalmologist.

DIFFERENTIAL DIAGNOSIS — The differential diagnosis of eyelid dermatitis is ample and includes common and less common skin diseases:

●Psoriasis – Psoriasis on the eyelids tends to be nonpruritic. Patients may manifest the typical scaly plaques of psoriasis on the body and scalp, and a full skin examination is essential for the diagnosis. Nail or joint disease may also be present, aiding in diagnosis. (See "Psoriasis: Epidemiology, clinical manifestations, and diagnosis".)

●Ocular rosacea – Ocular rosacea typically presents with lid margin telangiectasias and conjunctival injection. Crusted papules may be present on the eyelid margin (picture 3). The concurrent presence of acneiform papules and pustules, face flushing, and/or telangiectasias are a clue for the diagnosis of rosacea. (See "Rosacea: Pathogenesis, clinical features, and diagnosis".)

●Periorificial periocular dermatitis – Periocular periorificial dermatitis presents with patchy erythema and numerous tiny papules involving the eyelids and the periocular area (picture 4). A history of recent use of topical, nasal, or inhaled corticosteroids may be a clue to the diagnosis. (See "Perioral (periorificial) dermatitis".)

●Dermatomyositis – Dermatomyositis involving the eyelids tends to present with the classic "heliotrope rash" characterized by violaceous erythema (picture 5A-B). A biopsy shows interface dermatitis and not spongiosis. Pruritus is usually absent, and patients may have other symptoms of dermatomyositis, including scalp rash, extensor erythema, photosensitivity, characteristic nail changes, and muscle weakness, among others. Eyelid edema alone can be an early presenting sign. (See "Clinical manifestations of dermatomyositis and polymyositis in adults".)

●Nevus simplex – Newborns and infants may have asymptomatic, pink patches on the upper eyelids consistent with nevus simplex, which is a benign vascular birthmark (picture 6). Commonly called "stork bite" or "angel kiss," nevus simplex typically fades with aging. (See "Vascular lesions in the newborn", section on 'Nevus simplex (macular stain)'.)

Neonatal lupus – In infants, a rare cause of periocular dermatitis is neonatal lupus, which typically occurs in the first few weeks of life and can be associated with cardiovascular disease. A history of maternal lupus will aid in diagnosis. (See "Neonatal lupus: Epidemiology, pathogenesis, clinical manifestations, and diagnosis".)

MANAGEMENT — The management of eyelid dermatitis involves ongoing avoidance of exposure to irritants and allergens for patients with contact dermatitis and the use of topical anti-inflammatory agents, including topical corticosteroids and topical calcineurin inhibitors. There are no randomized trials assessing the efficacy and safety of these agents for eyelid eczema, and their use is based on limited evidence from small observational studies, indirect evidence based on their use in other types of eczema, and clinical experience [22-25].

Skin care — Conservative initial management of eyelid dermatitis includes gentle skin care and avoidance of fragrance and other known irritants in personal care, hair, and facial skin care products. Bland, fragrance-free emollients, such as petrolatum, may be applied directly to the eyelids.

Avoidance of irritants and allergens — For patients with a confirmed diagnosis of irritant or allergic contact eyelid dermatitis, ongoing avoidance of irritants and allergens (eg, soaps, scented or alcohol-containing cleansers, makeup products) is the mainstay of treatment. Petrolatum or other ointment-based emollients that are free of fragrance and other common allergens may be used. The use of perfume and aerosol hair sprays should be avoided.

Topical corticosteroids — We suggest low-potency topical corticosteroids as the first-line therapy for eyelid dermatitis:

●Administration – As the eyelids exhibit the highest percutaneous absorption on the body (and in the setting of active dermatitis, where the skin barrier is broken, the absorption may be even higher), only low-potency topical corticosteroids (groups 6 and 7 (table 1)) are safe for short-term use on the eyelids. We typically use low-potency topical corticosteroids twice daily for up to two weeks. If needed, treatment with topical corticosteroids can be repeated after a "steroid holiday" of one to two weeks before application is resumed.

However, patients requiring topical steroid treatment for more than four weeks should be switched to a topical calcineurin inhibitor. (See 'Topical calcineurin inhibitors' below.)

●Efficacy – In a small comparative study, 20 patients with moderate eyelid eczema and atopic keratoconjunctivitis were treated for three weeks with tacrolimus 0.1% ointment or clobetasone butyrate (a mid-potency topical corticosteroid) [23]. Both treatments were equally effective in reducing eyelid eczema and blepharitis signs and symptoms. No increase in the mean intraocular pressure (defined as an increase ≥2 mmHg) was noted in either group. However, one patient in the clobetasone butyrate group and one in the tacrolimus group developed an increase in the intraocular pressure of 5 mmHg that normalized in both cases after washout.

●Adverse effects – Prolonged use of topical corticosteroids in the periorbital area may induce a number of adverse effects (see "Topical corticosteroids: Use and adverse effects"). Even with low-potency topical corticosteroids, the eyelids remain vulnerable to thinning and atrophy. Long-term use of topical steroids on the eyelids can also lead to the development of a periorbital dermatitis, a rosacea-like eruption (picture 4). (See "Perioral (periorificial) dermatitis".)

Ocular complications may rarely occur with inappropriate use of topical corticosteroids in the periocular area [26]. Glaucoma has been reported from periorbital use of topical corticosteroids in case reports and small case series [27-31]; however, in those cases, the corticosteroid strength was higher than what would be typically recommended for use on the eyelids and/or the topical corticosteroid was used for a prolonged period. In a retrospective review of 88 patients with atopic dermatitis (AD), 37 patients had used topical corticosteroids (groups 3 and 4) on the eyelids and periorbital region, with an average frequency of 3.9 days per week and 6.4 months per year for 4.8 years. One patient had transient intraocular hypertension without glaucomatous changes, and two patients developed corticosteroid-induced cataract [27].

Topical calcineurin inhibitors — Topical calcineurin inhibitors (tacrolimus and pimecrolimus) can be used as an alternative to topical corticosteroids for the treatment of eyelid dermatitis in patients who require prolonged treatment (beyond four weeks). Topical calcineurin inhibitors are applied twice daily for two to four weeks or until improvement is noted, and then tapered. Treatment can be resumed if flares occur. The use of topical calcineurin inhibitors can initially be limited by a burning sensation when applied to inflamed skin, which improves with ongoing use.

The use of calcineurin inhibitors for eyelid dermatitis is supported by a few observational studies:

●In one study, 20 adult patients with moderate to severe AD of the eyelids and no pre-existing glaucoma, cataract, or elevated intraocular pressure were treated with tacrolimus 0.1% ointment twice daily for eight weeks and followed for two additional weeks after the last day of treatment [22]. Of the 16 patients who completed the treatment, 12 patients were clear or showed excellent improvement based on the physician global assessment score. None of the patients developed cataract, glaucoma, or increased intraocular pressure during the course of the study.

●In another study, 20 adult patients with long-standing allergic contact eyelid dermatitis were treated with tacrolimus 0.1% ointment twice daily for 15 days, followed by once-daily application for an additional 15 days [25]. Patients were then allowed to use topical tacrolimus once daily as needed for one month. Improvement from baseline was observed for multiple dermatitis parameters (erythema, edema, scaling, lichenification, itching, and burning). Treatment was well tolerated. Transient skin burning and itching was the only adverse effect reported by 12 of 20 patients.

●In a small comparative study, 20 patients with moderate eyelid eczema and atopic keratoconjunctivitis were treated for three weeks with tacrolimus 0.1% ointment or clobetasone butyrate (a mid-potency topical corticosteroid) [23]. Both treatments were equally effective in reducing eyelid eczema and blepharitis signs and symptoms.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Atopic dermatitis".)

SUMMARY AND RECOMMENDATIONS

●Epidemiology – Eyelid dermatitis or eczema is a relatively common condition presenting with a scaly, erythematous eruption of the upper and/or lower eyelids and periorbital area. It is more commonly seen in adults and teens, predominantly in females. (See 'Epidemiology' above.)

●Etiology – The cause of eyelid dermatitis is often multifactorial. It may result from contact with irritants or allergens, or can be a manifestation of an underlying skin disease, such as atopic dermatitis or seborrheic dermatitis. Allergens most commonly found to cause allergic contact dermatitis (ACD) of the eyelids include metals (eg, nickel, gold), fragrances and preservatives contained in cosmetics, and topical agents in prescription eye preparations. (See 'Etiology' above.)

●Clinical presentation – Eyelid dermatitis generally presents as an erythematous, scaly, pruritic rash on the upper and/or lower eyelids (picture 2A, 2C-D). It is bilateral in most cases but may be unilateral and affect the upper eyelids, lower eyelids, or both. Clinical findings may vary according to the etiology. Itching, burning, and pain are common symptoms. Lichenification from chronic rubbing and scratching may be also seen. (See 'Clinical manifestations' above.)

●Diagnosis – The diagnosis of eyelid dermatitis is made in most cases clinically, based on the characteristic appearance of the eruption, associated symptoms, and clinical history. Patch testing may be needed to identify patients with ACD. (See 'Diagnosis' above.)

●Management – The initial management of eyelid dermatitis involves ongoing avoidance of exposure to irritants and allergens and the use of topical anti-inflammatory agents. We suggest low-potency topical corticosteroids (groups 6 and 7 (table 1)) rather than topical calcineurin inhibitors as first-line therapy for eyelid dermatitis (Grade 2C). Topical corticosteroids are applied twice daily for up to two weeks. For patients requiring prolonged treatment for eyelid dermatitis (beyond four weeks), we suggest topical calcineurin inhibitors (ie, topical tacrolimus, pimecrolimus) (Grade 2C). Topical calcineurin inhibitors are applied twice daily until improvement is noted, and then tapered. (See 'Management' above.)