The Eyes Have It, and It Itches Like Crazy
DISCUSSION
For many patients, any problem that manifests close to the eye is deemed an “eye problem,” even when the eye itself is uninvolved. Eyelid dermatitis is an extremely common complaint, and this patient’s history is quite typical: The worse the problem gets, the more attempts the patient makes to relieve symptoms.
When this patient presented to dermatology, she was applying six different products (all OTC) to the affected areas. None helped, and in fact, most seemed to worsen the problem. Even if one had helped, she would never have known which. But desperation drives patients to do irrational things, especially when the problem is out in the open for the whole world to see.
Virtually every patient I’ve seen with eyelid dermatitis has (like this patient) already stopped using makeup and changed or discontinued use of laundry detergent and other products. These are almost never the problem; if any of them were, the effects would not be so sharply limited to the periocular area.
Rather, the sharp margins of this condition suggested irritant contact dermatitis. It often appears in this context: The periocular skin is unique in that it’s the thinnest in the female body. This means it is easily traumatized by rubbing and scratching and can be quite permeable to various contactants. This is especially true in atopic patients, whose skin is not only thin and dry but also overreactive to insult.
Though we may never know the full story, I suspect this patient had a more modest case of eczema on her eyelids until she began to apply product after product. One of them—triple-antibiotic cream—is a notorious topical sensitizer. In one sense, this patient is a victim of overattention to the problem.
I advised her to stop use of all the contactants and prescribed hydrocortisone 2.5% ointment for twice-daily application. I also gave her a prescription for a two-week taper of prednisone. When she returned for follow-up three weeks later, the rash was completely resolved.
Other conditions that can cause eyelid dermatitis include seborrhea and psoriasis.
TAKE-HOME LEARNING POINTS
• Eyelid dermatitis, an extremely common complaint, is rarely seen in men and is almost never caused by makeup, soap, or shampoo.
• Eyelid dermatitis is not an eye problem—rather, it is a skin problem that happens to occur near the eye.
• The differential for eyelid dermatitis includes atopic dermatitis, seborrhea and psoriasis.
• Stopping use of all contactant products (except prescription medications) is necessary.
• Class 5 or 6 steroids, especially hydrocortisone 2.5% in ointment form, are useful. In severe cases, a tapering course of oral glucocorticoids (prednisone) is extremely helpful.
