Many cases of non-infectious eyelid swelling and eyelid skin rash are from sensitivity to hair products, soaps, nail polish, cyanoacrylate glue, swim goggles or past cosmetic filler. Blepharochalasis syndrome, Melkerrson Rosenthal syndrome, and cerebrospinal fluid leak post trauma are rare causes of lid swelling.
If you have a suspected skin allergy try the following first: Notes modified from Dr. Melanie Pratt (University of Ottawa) and Dr. Skotnicki’s (Bay Dermatology Centre, Suite 536, 790 Bay Street Phone: (416) 515-8808 Fax: (416) 515-8805) Lecture on Eyelid Dermatitis
REMOVE ALL POTENTIAL IRRITANTS. Nail polish. Hair dyes. Shampoo, soap, facial cream/lotions, makeup, makeup applicators, topical medications, nickel glasses or rings
Anything with FRAGRANCE is an irritant. Fragranced hair care products, hand and body moisturizers.
Botanicals and natural products can irritate. **Natural and Botanical products are NOT better since they may contain fragrance Mica/shimmer makeup can irritate. Sunscreens can irritate. Antibiotic ointments and preps. The benzalkonium chloride in eye drops can irritate.
“Hypoallergenic” and “Sensitive skin care” do NOT mean fragrance free. The product must specifically say on the label that it is fragrance free.
If asymmetric lid involvement consider ectopic contact dermatitis from the hands.
If spread beyond the lids consider allergic contact dermatitis from product applied to the face.
If spread behind the ear, consider seborrheic dermatitis or psoriasis.
If limited to lid, consider irritant dermatitis.
If medial upper lid consdier psoriasis or lichen simplex chronicus (LSC)
Soaps and shampoos: cocoamindopropylbetaine (foaming agent in shampoo), fragrance, formaldehyde releasers (quaternium-15, Diazolidinyl urea pet, imidazlidinyl urea pet, 2-bromo 2 nitropropane-1,3diol, DMDM hydantoin), methylchloroisothiazolinone, methylisothiazinolone, methlisothiazinolone. A minor allergen could be parabens.
Hair dyes: paraphenlenediamine; 2-5 diaminotoluene sulfate
Facial moisturizers: formaldehyde releasers, fragrances, parabens, methyldibromo glutaronitrile, iodopropynbutylcarbamate
Contact lens solution
COMMON SKIN ALLERGENS: Nickel, Balsam of Peru, Neomycin, Fragrance, Quaternium, Cobalt, Bacitracin, Formaldehyde, Methyldibromo glutaronitrile
Neomycin cross reacts with gentamycin, tobramycin, framycetin (soframycin), bacitracin
Wash: Dove bar, Cetaphil, CeraVe, Cliniderm
Moisturizer: Cetaphil, CeraVe, Cliniderm
Shampoo: Cliniderm (*Dove shampoo has fragrance!)
NO makeup temporarily. Avoid all makeup with shimmer/glitter (mica)
Cortate 1% ung or Prevex HC. (No Protopic 0.1% ung until after irritation settled)
After the skin is clear reintroduce one product at a time q 5 days (Cosmetics from Clinique, Marcell and Almay are sometimes better tolerated in some patients than others)
If recurrrence patch test
SEBORRHEIC DERMATITIS: steroids, antifungals, wash face with dandruff shampoo
ATOPIC DERMATITIS AND LICHEN SIMPLEX CHRONICUS: (usually an obvious atopic patient with seasonal allergies, hay fever and asthma). Try antihistamines and protopic 0.1% Lichen simplex chronicus can be seen in non-atopic patients too
EYELID DERMATITIS modified from John Kraft, MD and Charles Lynde, MD December 2008
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 prone to contact dermatitis due to the thinness of the skin. Eyelids are 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, eyelids 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.
CLINICAL FINDINGS 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. Avoid all wet nail polish. 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 glaucoma drops, 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 and glasses.
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.
DIFFERENTIAL DIAGNOSIS 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.
Table 1 – Sources of allergic contact dermatitis of the eyelids
- nail polish (especially wet nail polish)
- artificial nails
- bleaching agents
- hair dyes
- perfumed hair sprays
- glaucoma drops
- contact lens solution
- eyelash curlers
- nail file
- poison ivy
- poison oak
- poison sumac
- materials person is handling
- rubber (eyelash curlers, makeup sponges), metals, glues, newsprint
- household sprays
- animal hairs
- occupational volatile chemicals
- “strike anywhere” matches
- facial tissues
Table 2 – Differential diagnosis of eyelid dermatitis
- allergic contact dermatitis
- irritant dermatitis
- atopic dermatitis
- seborrheic dermatitis
- rosacea/perioral dermatitis
- collagen vascular disease — lupus, dermatomyositis
- secondary to conjunctivitis or blepharitis
- urticaria — contact and systemic
- COMBINATIONS OF THE ABOVE CAN BE POSSIBLE
A skin rash can signal many things, but is often the result of an allergy. Redness and itchiness, with or without hives, often indicate a skin allergy. Skin allergies are caused by allergic contact dermatitis.
“Allergic contact dermatitis” is the term used for a rash or irritation of the skin that occurs when allergens, substances that the immune system reacts to as foreign, touch your skin. It’s estimated that atopic dermatitis affects up to 3 percent of adults. Some common skin allergy triggers are listed below.
Hair Dye Contact dermatitis from hair dye is caused by sensitivity to para-phenylenediamine (PPD), which is found in permanent hair dyes that are mixed with another chemical, such as peroxide, before they’re applied. About 25 percent of people who are allergic to PPD are also allergic to ingredients found in semipermanent hair dyes. Follow the instructions on hair dye packaging for patch-testing for sensitivity before applying dye to your whole head. Another culprit: temporary black henna tattoos, because PPD is added to regular henna to make the color darker or black. A dermatologist can perform a patch test that will help determine if you are allergic to common allergens such as hair dye.
Cosmetics Wet nail polish is the most common cause of eyelid dermatitis. Once the nail polish is dry, you may be able to touch your face and eyes, but you should avoid contact until it is completely dry.
Allergic reactions to cosmetics can be induced by fragrance allergies, but they may also be caused by preservatives used in cosmetics. Skin irritation is a common problem at the site of contact with cosmetics and may be experienced by anyone, but allergic reactions such as redness, swelling, and hives tend to occur in people who are allergic to specific ingredients, like formaldehyde, parabens, and thimerosal.
If you experience a cosmetics allergy, stop using all cosmetics, and then gradually reintroduce products into your routine to isolate the culprit
Fragrances and Perfumes Perfumes and fragrances are among the most common causes of contact allergies in adults, and this type of allergy is on the rise. But it’s not just the stuff you use to smell good. Fragrances that may cause an allergic reaction are found in hundreds of products, including shampoos, soaps, body washes, and household products like room sprays, cleaners, laundry detergents, and dryer sheets. Even products labeled “unscented” can cause contact dermatitis because they may contain a fragrance designed to block unwanted scents. Research has shown that natural oils can also cause allergic reactions. If you’re prone to fragrance allergies, look for fragrance-free products.
Topical Medications Antibiotic creams and ointments are useful in treating cuts — except among people with an allergy to neomycin, an ingredient found in topical antibiotics and anesthetics used to provide pain relief, such as creams, ointments, ear drops, and eye drops. These medicines are drying to the skin and create more of an irritant reaction rather than an allergic reaction. People with a sensitivity to neomycin experience inflamed rashes at the point of contact. If you think you may be allergic to neomycin, an allergist can perform a skin patch test to confirm it. Atropine drops can also cause contact skin allergy.
Household Products that may cause skin allergies include solvents and adhesives — for example, cyanoacrylate, a common household adhesive found in superglues, can cause an allergic reaction. In addition, household cleaning products may include organic solvents, which are used to dissolve stains and grease. Products that contain potent solvents, such as charcoal lighter fluid, paint thinner, furniture stripper, and nail polish remover, may induce skin allergies / skin irritation. An allergic reaction can look like hives, or red patches that are usually very itchy.
Fabrics and Clothing The most common fabric-related allergy is an allergy to formaldehyde resins, which are used to make fabrics waterproof and resistant to wrinkles and shrinkage. They are also used in elastics, and some people develop a rash around the abdomen when elastic in undergarments is exposed with wear. If you experience formaldehyde allergy symptoms, such as burning eyes, skin rashes, and chest tightness, look for clothing that’s only lightly treated with resins, such as pure cotton, polyester, nylon, and acrylic. Often, people who are allergic to formaldehyde in fabric can tolerate clothing that has been washed many times.
Although many people believe they are allergic to wool, a true wool allergy is rare. People are usually just sensitive to the texture of the fabric.
Sunscreen The lotion you slather on to protect yourself from the sun could have an unwanted effect — but only if you go out in the sun while you’re wearing it. That might sound bizarre, but some chemicals that are harmless by themselves are converted into allergens when they are exposed to the ultraviolet rays of the sun. This type of allergic reaction is called a photocontact allergy, or photoallergic reaction. While certain substances used in sunscreens can cause direct allergic reactions in some people, they cause the reaction in others only when they go out in the sun. Common sunscreen ingredients that can cause allergic reactions include PABA (para-aminobenzoic acid), benzophenones, oxybenzone, salicylates, and cyclohexanol.
Nickel is used to create metal alloys found in many metal products including jewelry – even some gold jewelry and body piercings. Nickel is also found in eyeglass frames, watchbands, zippers, and other metal fasterners, such as buckkles, buttons, snaps and hooks. Nickle-sensitive people can use nylon or coated-metal fasterners instead.
Latex If your skin becomes red and itchy when you wear rubber gloves, you may be allergic to latex, a milky fluid that comes from rubber trees and is processed to make balloons, waistbands on clothing, rubber bands, condoms, and other products. The allergy is a reaction to certain proteins in latex that your body mistakes for harmful substances. Symptoms can range from mild (rashes, itchy eyes) to severe (difficulty breathing, vomiting). If you have a latex allergy, you can reduce your risk of a reaction by avoiding contact with latex and using substitutes, such as nonlatex gloves.
Poison Ivy The common weed poison ivy contains an oil, called urushiol, that can cause an allergic reaction. Urushiol is also found in poison oak and poison sumac, which grow as bushes or small trees. Surprisingly, not everyone is allergic to urushiol. For those who are, symptoms of poison ivy rash include itchy skin, redness, hives, and blisters. Urushiol is sticky, so you can get a rash from touching something that came in contact with it — your pet’s fur, your shoes, or firewood, for example. You can experience a poison ivy allergy only if you are exposed to urushiol; the resulting rashes are not contagious. These rashes can usually be treated at home by washing the affected area with cool water and applying nonprescription antihistamines and calamine lotion. Severe cases may require a visit to the doctor.
Allergy Asthma Proc. 2012 Mar-Apr;33(2):205-11. A 44-year-old man with bilateral eyelid swelling.Ricketti AJ, Cleri DJ, Moser RL, Bilyk JR, Vernaleo JR, UnkleDW. Swollen eyelids are commonly ascribed to allergic conjunctivitis, contact dermatitis, eczema, angioedema, or acute sinusitis. The differential diagnosis extends to thyroid eye disease; blepharitis; Sjögren’s syndrome; Churg-Strauss vasculitis; Wegener’s granulomatosis; Gleich syndrome;orbital and ocular lymphoid hyperplasia or adnexal lymphoma; idiopathic orbital inflammatory disease/idiopathic sclerosing orbital inflammation; rarely, orbital parasitosis; and IgG4-related diseases.