A closer look at periorbital allergic dermatitis

The signs and symptoms are usually periorbital edema, erythema, and skin flaking with itching from minimal to severe. Image credit: AdobeStock/madrolly

I have seen an increase in periorbital contact dermatitis over the winter months with a variety of histories and presentations. I have my “go-to” treatment plan, but some of these cases can be tough to treat if the offending agent is a mystery. These patients are motivated to resolve this as quickly as possible as they are highly symptomatic and bothered by its location.

Figure 1. Periorbital contact dermatitis. Observe the edema in the upper lid folds and along the lash line, along with mild erythema and skin flaking below the eyebrows.(Courtesy of Shawna L. Vanderhoof, OD, FAAO)

The signs and symptoms are usually periorbital edema, erythema, and skin flaking with itching from minimal to severe. Some say pressing on their eyes is helpful. Some prefer hot compresses, and some prefer cold compresses as their initial treatment before calling the office. For example, the patient in Figure 1 had these symptoms upon waking and denied using any new products, including facial lotions, serums, detergents, and soaps. Besides ocular and periocular skin itching, there were no other symptoms. She had even left her home for vacation, and these symptoms persisted. The culprit was finally discovered: The dog beds were harboring some allergen that the dogs brought in from outside. Therefore, the allergen was still bothersome to the patient even on vacation. Another patient similarly discovered that her contoured sleep mask contained latex, causing her morning symptoms.

Periorbital dermatitis is caused by a contact allergy in 44% to 54% of all cases, followed by atopic dermatitis/eczema in 25% of cases; the less frequent causes are periorbital rosacea, psoriasis, or allergic conjunctivitis.^1,2 Females older than 40 years with a history of atopy are the most affected.

An irritant or an allergen can cause contact dermatitis. An irritant damages the skin, and it is a nonallergic reaction. An allergen will trigger an immune response within the skin, but it may have been ingested or come in contact with the area of skin that has reacted. Irritant contact dermatitis is most common around the face; the irritant damages the stratum corneum epidermis, “which is the outermost superficial epidermal layer that serves as the first line of defense between the body and the environment, and the lower part of this layer is crucial in preventing the penetration of irritants and allergens.”³

Cosmetics or products you leave on, such as creams containing chemicals or metals, are common culprits of periorbital allergic contact dermatitis. Detergents or soaps are also considered irritants. Examples of allergens are fragrances, dyes, nickel, or plants (poison ivy/oak).

Figure 2. Initial presentation of periorbital contact dermatitis. (Courtesy of Shawna L. Vanderhoof, OD, FAAO)

Irritant and allergen periorbital contact dermatitis both clinically present with erythema, edema, and a pruritic/itchy or burning rash with possible vesiculation, as in Figure 2. Dryness leads to scaling or shedding/flaking of the skin. I see this as a classic sign of contact dermatitis, as in Figure 1.

To treat this successfully, we must identify the culprit and avoid it. If avoided, it will clear up within a couple of weeks. This is what makes these cases difficult to treat. A specific discussion of recent history emphasizing new facial products, detergents, activities (especially outside), or foods is critical to solving the mystery. These symptoms can present within hours to days after exposure and worsen after repeated exposure. During this time of avoidance, a treatment plan should be implemented to get immediate relief for patients.

Treatment plan #1

The first step is to identify and avoid the irritant or allergen.

Topical treatments:

Apply a topical steroid ointment such as triamcinolone acetonide 0.1% twice daily to affected areas for 1 week, then stop. I emphasize to the patient that the ointment does not go into the eye, and I also place that warning in the instructions on the prescription sent to the pharmacy. I also educate the patient on the risks of long-term steroid use, such as thinning of the skin.

Oral medications:

The patient may take over-the-counter oral antihistamines as directed, such as cetirizine (Zyrtec), fexofenadine (Allegra), or loratadine (Claritin). These are considered nondrowsy. Diphenhydramine (Benadryl) can be highly effective but can cause significant drowsiness. I usually avoid diphenhydramine in older patients and those who take antidepressants, β-blockers for high blood pressure, or sleep aids.

Figure 3. Two weeks after initial presentation, the patient shown in Figure 2 still presents with symptoms. (Courtesy of Shawna L. Vanderhoof, OD, FAAO)

I have the patient return in 2 weeks for a follow-up appointment. Most of the time, the issue has resolved itself. For cases that have not resolved, as in Figure 3, we must review what we have ruled out.

Treatment plan #2

Upon the second presentation, practitioners should still try to identify and avoid the irritant or allergen.

Behavioral changes/questions:

Confirm that the patient has not used any new products since their previous appointment. Have they eaten any new foods? Are there any new plants in the home or garden? Do they change pillowcases often? How old is their pillow? Have pets been sleeping on their bed? Do they shower at bedtime? One or more of these answers may lead to the culprit.

Topical treatments:

Apply tacrolimus 0.1% (Protopic) twice daily to affected skin for 6 weeks or less. This is approved for patients 15 years or older, and tacrolimus 0.03% is approved for patients 2 to 15 years. Topical steroids should be applied 2 to 4 times daily in both eyes, depending on the symptoms.

Oral medications:

If the oral antihistamines are helping, continue.

I have the patient return for a follow-up appointment in 2 to 4 weeks. If it has not completely resolved, you can continue treatment plan #2 for another 2 to 4 weeks and recommend a dermatologist or allergist referral. The patient must stop all treatments before seeing an allergist for testing.

Sometimes, eye drops cause periorbital dermatitis. β-Blockers (timolol) and carbonic anhydrase inhibitor (brinzolamide or dorzolamide) eye drops that contain benzalkonium chloride have been shown as the culprit even after years of use, especially in those with a worsened visual field index and a history of ocular surgery.⁴ Discontinuing the drop showed complete recovery in 2 to 4 weeks.

Figure 4. Heliotrope rash, which presents as a purplish periocular rash. (Courtesy of: https://teesneuro.org/specific-conditions/myopathy/heliotrope-rash/)

Nearly 75% of children with type 1 diabetes develop a purplish periorbital rash known as a heliotrope rash, as seen in Figure 4. This rash is diagnostic for autoimmune dermatomyositis, which can also be preceded by muscle weakness.⁵ The treatments outlined above will help in these cases, but a referral to their pediatrician to rule out autoimmune issues would be warranted, especially if their history indicates no new irritants or allergens introduced recently.

These periorbital contact dermatitis cases are difficult, and it does take time to figure out the offending agent(s). Still, we have a few options that can help during our investigation.

References:

1. Skin and lacrimal drainage system. In: Yanoff M, Sassani J. Ocular Pathology. 8th Ed. Elsevier; 2020:163-233.

2. Feser A, Mahler V. Periorbital dermatitis: causes, differential diagnoses and therapy. Article in English, German. J Dtsch Dermatol Ges. 2010;8(3):159-166. doi:10.1111/j.1610-0387.2009.07216.x

3. Cork MJ, Robinson DA, Vasilopoulos Y, et al. New perspectives on epidermal barrier dysfunction in atopic dermatitis: gene-environment interactions. J Allergy Clin Immunol. 2006;118(1):3-21; quiz 22-3. doi:10.1016/j.jaci.2006.04.042

4. Kim M, Jang H, Rho S. Risk factors for periorbital dermatitis in patients using dorzolamide/timolol eye drops. Sci Rep. 2021;11(1):17896. doi:10.1038/s41598-021-97565-0 

5. Cohen BA. Reactive erythema. In: Schachner LA, Hansen RC, eds. Pediatric Dermatology. 4th Ed. Saunders; 2013:169-210.