Eyelid dermatitis (overview) H01.11

Author: Prof. Dr. med. Peter Altmeyer

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Last updated on: 29.10.2020

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Synonym(s)

Eczema Eyelid eczema; eczema of the eyelids; eyelid dermatitis; Eyelid dermatitis; eyelid eczema; Eyelid eczema; Eyelid Inflammation

Definition
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Pathogenetically heterogeneous dermatitis with acute, subacute or (frequently) chronic inflammation of the eyelids, which is essentially characterized by the special anatomical conditions (moist contact situation of the superimposed eyelid folds with reservoir character for toxic or allergenic substances) and functionality of the eyelid organ.

Classification
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Depending on the aetiology of the eczema can be divided:

  • eyelid dermatitis, atopic (10-20% of eyelid dermatitis)
  • Eyelid dermatitis, contact allergies (about 50% of eyelid dermatitis)
  • Eyelid dermatitis, toxic-irritant (15-20% of eyelid dermatitis)
  • Eyelid dermatitis, seborrheic (3-6% of eyelid dermatitis)
  • Rare forms:

Occurrence/Epidemiology
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Since the aetiology of eyelid dermatitis varies, a general figure cannot be given. It is known that about 12% of the hypersensitivities to cosmetics lead to eyelid dermatitis.

Etiopathogenesis
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Etiologically, contact allergens (most frequent cause: in 54.2% of cases eye drops, followed by creams and lotions (24.6%) and various cosmetics (13.1%), a seborrhoeic or atopic diathesis play an important role. Possible triggers see table 1.

Manifestation
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Atopic eyelid dermatitis can occur in early childhood (together with other atopic stigmas).

Contact allergic eyelid dermatitis manifests itself significantly later, in early or middle adulthood. In a larger study involving 61 patients (Chisholm SAM et al. 2017) the mean age was 66 years (33-94). 74% of the patients were women.

Clinical features
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Mostly chronic dynamic, permanent or recurrent clinical picture, in which a blurred erythema, swelling of the eyelids and itching characterize the picture. Depending on the persistence of the inflammation: scaling, lichenification with distinct thickening of the eyelids, pruritus of rare oozing with crust formation as well as disorders of the eyelid functions (danger of ectropion or ectropion with consecutive consequences for the eye).

In a larger study involving 61 patients (Chisholm SAM et al. 2017), tears (epiphora), ectropion (24.6%), blepharitis (18.0%), ptosis of the eyelids (14.8%) were the cause for the visit to the doctor in 1/3 of the patients.

In rare cases, pruritus may be absent, making it difficult to distinguish it from other diseases, especially thyroid diseases, angioedema, collagenosis, nephropathies, lymphoma of the skin.

Diagnosis
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  • The diagnosis of eyelid eczema consists primarily in the exclusion of contact eczema. The dark figure of undetected contact allergens is high.
  • The anamnesis plays an important role:
    • Perennial eyelid dermatitis: Not caused by pollen; eczema of the eyelid even during longer stays away from home. Exclusion of indoor allergens is necessary.
    • Seasonal eyelid dermatitis: Cosmetic allergy unlikely.
  • In addition to allergens that come into direct contact with the eyelid region (mascara, eye make-up, ophthalmics, contact lens cleaners), substances that come into contact with the eyelid region indirectly (via fingers) often trigger isolated eyelid dermatitis (allergen carry-over). On average a person rubs the eyelids 50-100 times a day, often unconsciously. In principle, any substance in the environment can be a possible trigger.
  • Substances applied to other parts of the body can trigger isolated contact eczema in the eyelid area without causing reactions at the actual application site (low degree of sensitization or low allergen concentration, but low skin thickness and occlusion effect in the eyelid area).
  • A negative epicutaneous test does not exclude contact allergic eyelid dermatitis caused by cosmetics.
  • Weak reactions in the epicutaneous test on cosmetics may represent real sensitizations. If necessary, repeat the test procedure in a " Repeated open application test (ROAT)". In this test, the suspected substance is applied to the inner side of the upper arm twice a day for 1 week. A further possibility for clarifying clinical relevance is open epicutaneous testing in loco.
  • Allergens in nail varnish (nickel, toluene sulfenamide formaldehyde resin) trigger eyelid and facial eczema, fingers remain free of skin appearance.
  • Allergens can also be "transferred" by the partner (aftershave of the partner in case of fragrance sensitization).
  • In the eyelid area, contact eczema is also possible due to volatile allergens such as type IV allergens(formaldehyde, primin) or type I allergens (pollen, house dust mites), see below Airborne Contact Dermatitis.
  • Spectacle frames made of "metal" may not release nickel on the surface according to the prescription. However, the core of the spectacles often still consists of nickel, so nickel may be released when the spectacles age and wear.

Differential diagnosis
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In descending frequency the following diseases can be assigned to the clinical appearance "eyelid eczema":

Complication(s)
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Risk of bacterial superinfection with staphylococci. In atopic eyelid eczema there is a danger of Eccema herpeticatum. Furthermore, atopic eyelid eczema leads to a functional disturbance of the eyelid organ with production of a pathological mucin with increased viscosity and a tendency to increased mucus formation. The consequence is chronic keratoconjunctivitis, which aggravates the overall problem.

Therapy
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The detection of underlying sensitizations and subsequent exposure leave is in the foreground of any therapeutic approach!

  • In case of contact allergic dermatitis: switch off the allergen. In case of atopic genesis there is a tendency to chronicity and resistance to therapy.
  • Acute eczema: hydrocortisone: 0.5% in a preferably neutral base (Vaselinum alb.) or eye preparations containing glucocorticoids (e.g. Ficortril eye ointment).
  • After the acute phase has subsided, the glucocorticoid is removed, alternate treatment with the pure base, and finally, nourishing therapy with ointments containing dexpanthenol(e.g. Bepanthen eye ointment Cave! wool wax allergy!) or eye vaseline.

Notice! Avoid higher potent glucocorticoids for the eyelid area, danger of steroid atrophy!

  • In acutely exacerbated atopic dermatitis, short-term therapy with an external glucocorticoid on an indifferent basis (see below). In the case of severe symptoms, internal glucocorticoid administration (prednisolone 1 mg/kg bw), possibly in combination with an oral antihistamine such as desloratadine (Aerius) once/day 5 mg p.o.
  • Chronic atopic dermatitis: The problem is that many anti-eczematous agents cannot be applied in the eye area. Short-term hydrocortisone 0.5-1% in a preferably indifferent base (e.g. Vaselinum album: Hydrocortisone ointment 1%). Additional compresses with cold black tea, Tannolact solution or physiological saline solution (also cool tap water). Application: Apply ointment to eyelids, rest for 20 minutes, apply soaked compresses.
    • Alternative to glucocorticoids: Good results (according to the present state of knowledge, however, no long-term therapy is possible because of the unclear long-term effects) are achieved with intermittent application of topical immunomodulators (e.g. Tacrolimus, Pimecrolimus). Because of the unknown long-term effects of calcineurin inhibitors and the carcinogenicity of Pimecrolimus proven in animal experiments, the indication for the therapy with calcineurin inhibitors has to be set very strictly!
    • Alternative: Magistral prescription of a 1,0-2,0% Ciclosporin-containing solution ( R047 ).

General therapy
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General therapeutic advice:
  • Patience of therapist and patient is important. The etiological mechanisms of the present eyelid eczema must be explained to the patient. Avoiding the allergen is to be given the highest priority.
  • Cleaning of the eyelids with pure olive oil (apply with cotton wool carrier and dab the eyelids gently). Especially in case of aerogenic contact allergy the cleaning procedures are important (allergen removal especially in the evening!).
  • Eyelid edge care: Special care of the possibly encrusted eyelid edges is important. Apply moist compresses (see above); then carefully clean the eyelid margins with a cotton swab.
  • Long-term therapy: Nursing measures with indifferent external agents such as simple eye ointment DAC (e.g. R021 ) or emulsifying eye ointment (e.g. R022, R023 ).

Progression/forecast
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The average duration of symptoms in a larger study was 16.5 months.

Naturopathy
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Black tea surcharges are not recommended as an alternative but as a supplement. Using advice: Boil 1 tbs. in 0.5 l water for 15 min., strain, let cool, then use as a pad several times a day (cotton pads). Do not use flavoured teas. As an alternative to teas, you can also use oak bark extracts.

Tables
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Possible triggers of allergic eyelid dermatitis (and facial dermatitis)

Detergents

soap, washing lotions, face milk, bath additives

Cosmetics

Make-up, make-up and its removers, face mask, face creams, shaving foam or water, perfumes, sunscreens, artificial tanning products, refreshing tissues

Hair Care

Shampoo, dry shampoo, spray, setting lotion, hair tonic, tinting or colouring agent, cream rinses, hairdressing cream, perm water, cold wave, wig, wig care products (often eyelid eczema combined with facial and head eczema)

Lip Care

Lipstick, lipstick ointment

Eyelash cosmetics

eyelid and mascara, eye shadow, eyebrow pencil

Nail Cosmetics

Nail polish (nickel in metallic nail polish), artificial fingernails, nail polish remover

Personal care products

Body lotions, Hand creams, Body spray, Body powder

Therapeutics, Ophthalmics

Antiseptics (polyvidon), non-steroidal anti-inflammatory drugs (diclofenac), anaesthetics, glucocorticoids, antibiotics (gentamicin, chloramphenicol), mydriatica, preservatives (benzalkonium chloride, thiomersal), herpes therapeutics, carboanhydrasehalter e.g. dorzolamide (for glaucoma therapy)

Contact lenses

general incompatibility with increased lacrimation and consecutive eyelid irritation (usually in stripes around the lateral corners of the eye), contact allergens in cleaning and storage liquids

Detergents

among other things fragrances (Peru balsam!)

occupational allergens, hobby

according to medical history

Budget

metal, floor, car, furniture polish, floor polish, shoe polish, stain remover

Indoor allergens

Plants (primroses), room spray, carpet cleaner; house dust mites, animal epithelia (type I sensitisers)

Note(s)
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Changes to the eyelids lead to a dermatological consultation at an early stage, since the eyes, including their eyelids, are of great aesthetic importance. The eyelids serve as protective organs for the oculi bulb. An intact eyelid is responsible for the constant wetting of the eye surface with a continuous film of tears. With eczematous eyelids, this function can be disturbed, which can cause permanent irritation of the conjunctiva and cornea.

Literature
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  1. Adams RM et al (1985) A five-year study of cormetic reactions.J Am Acad Dermatol 13:1062-1065
  2. Beltrani VS (2001) Eylid dermatitis. Current Allergy and Asthma Reports 1: 380-388
  3. Chisholm SAM et al (2017) Etiology and Management of Allergic Eyelid Dermatitis. Ophthalmic Plast Reconstr Surgery 33:248-250.

  4. Guin JD (2004) Eyelid dermatitis: a report of 215 patients. Contact Dermatitis 50: 87-90

  5. Wollenberg A et al (2004) Diagnosis and treatment of eyelid eczema. An interdisciplinary challenge. dermatologist 55: 677-687

Disclaimer

Please ask your physician for a reliable diagnosis. This website is only meant as a reference.

Authors

Last updated on: 29.10.2020