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Contact Dermatitis

ROUTINE — Adnexa

Symptoms

Sudden onset periorbital rash

Intense pruritus (itching)

Eyelid swelling

Clinical Findings

Cutaneous

  • Periorbital edema and erythema
  • Vesicles, scaling, and crusting
  • Lichenification (skin thickening) in chronic cases

Ocular

  • Watery discharge
  • Conjunctival chemosis or papillary reaction

Etiology

Immune mechanism

  • Type IV delayed cell-mediated hypersensitivity: reaction occurs 48–72 hours after re-exposure (distinguish from Type I immediate allergy).
  • Atopic diathesis: patients with asthma or hay fever are at higher risk due to compromised skin barriers.

Ophthalmic culprits

  • Benzalkonium chloride (BAK): most common preservative; high risk in chronic glaucoma patients.
  • Neomycin: aminoglycoside in triple-antibiotic ointments; up to 10% sensitization rate.
  • Others: aminoglycosides (tobramycin, gentamicin), brimonidine (often delayed onset), apraclonidine, atropine, trifluridine, and thimerosal.

Non-ophthalmic triggers

  • Cosmetics: nickel (eyelash curlers), paraphenylenediamine (hair dye), fragrances, formaldehyde.
  • "Nail-to-lid" transfer: nail polish or acrylics transferred by fingers to the eyes.

Irritant VS allergic

  • Irritant: direct cytotoxicity from soaps/detergents (non-immune).
  • Allergic: immune-mediated; requires patch testing for confirmation.

Red Flags

Corneal involvement with periorbital swelling → stop agent; check for infection; consider topical steroid.

Associated atopic dermatitis with keratoconus or cataract → monitor for ocular sequelae.

Severe bilateral reaction → evaluate for systemic contact allergens (cosmetics, preservatives).

Chronic relapsing course → dermatology referral for patch testing.

Investigations

Clinical history

  • Review all topical agents: eye drops (BAK, neomycin), cosmetics, nail products, and hair dyes.

Examination

  • Slit-lamp exam to assess periocular skin, conjunctival chemosis, and papillary reaction.

Diagnostic testing

  • Trial of discontinuation: monitor for resolution within days of stopping suspected agent.
  • Patch testing: T.R.U.E. test or expanded ophthalmic panel (Gold Standard for recurrent cases).

Treatment

Allergen avoidance

  • Discontinue suspected triggers (neomycin, BAK-preserved drops, cosmetics, nickel).

Skin & surface care

  • Cool compresses for symptomatic relief.
  • Preservative-free artificial tears for ocular surface irritation.

Pharmacotherapy

  • Topical: hydrocortisone 1% ointment to eyelid skin for 1–2 weeks.
  • Systemic: oral antihistamines (cetirizine, loratadine) for itching.

Clinical Pearl

Periocular dermatitis in a "raccoon" pattern usually implies a topical allergen; neomycin, BAK, and nail polish are the most frequent culprits.

Differential Diagnosis

  • Varicella zoster virus (shingles)
  • Impetigo
  • Preseptal or orbital cellulitis

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