The most common cause of eyelid skin problems in Finland is atopic eczema.
Keep in mind dry eyes as a factor that may be either causative or an aggravating factor.
It is also important to examine other areas (the scalp, other skin areas, nails, ears) because diagnostic signs can often be found in areas other than the eyelids.
Keep in mind the possibility of allergic contact dermatitis (cosmetics, skin care products, eye drops).
Tender, erythematous, swollen area at the medial canthus, sometimes with fever
Dacryoadenitis
Swelling and erythema at the upper lateral canthus, usually after a viral infection
Diagnosis
Good history taking and clinical examination form the cornerstones of diagnosis.
Does the patient have a history of skin disorders, such as atopic eczema or psoriasis?
Could there be contact allergy? Has the patient developed reactions to foundation or eye drops, for example?
Is there any temporal connection with the initiation of topical treatment in the eye area (e.g. eye drops used to treat glaucoma)?
Does the patient have pain or general symptoms (infections)?
Check other areas (scalp, other skin, nails, ears, etc.).
Workup
Atopic eczema in adults is usually not directly associated with IgE-mediated allergy. However, IgE-mediated aggravation of eyelid eczema is possible (e.g. due to pollen or animal dander), and this may warrant prick testing or determination of specific IgE antibodies. Patients usually also have symptoms of allergic conjunctivitis.
Epicutaneous tests may be indicated if allergic contact dermatitis is suspected.
Skin biopsy is normally not useful (no specific histology).
In seborrhoeic eczema, Malassezia yeast may be seen in samples sent for microscopy but fungal culture may still be negative. The diagnosis should be based on clinical features.
In purulent blepharitis resistant to treatment, bacterial culture may be useful.
If Herpes simplex or H. zoster is suspected, emergency consultation of an ophthalmologist is indicated.
Treatment
Causal treatment, if possible (e.g. avoidance of the triggering factor in allergic contact dermatitis)
Eyelids are particularly sensitive to the adverse effects of topical glucocorticoid ointments (telangiectasis, atrophy, increased intraocular pressure, cataract). High-potency glucocorticoid ointments should not be applied to the facial area.
In atopic eczema, the treatment of first choice is mild topical glucocorticoids intermittently in courses of 1 to 2 weeks, for example. It is considered that no more than one course per 3 months can be safely given.
In cases resistant to treatment, topical calcineurin inhibitors (tacrolimus and pimecrolimus) are also highly effective, such as a 0.03% tacrolimus ointment once daily, at night, for 1 to 2 weeks and subsequently twice weekly.
For dry eyes, drops reducing the evaporation of tear fluid should be used several times a day.
Non-medicated eye ointments may also be useful for patients with atopic eczema and dry eyes.
Patients who additionally have symptoms of allergic conjunctivitis will benefit from the use of eye drops containing cromoglycate or an antihistamine. Because of their drying effect antihistamine eye drops should be combined with moisturizing eye drops Conjunctivitis.
Mild topical glucocorticoids and topical calcineurin inhibitors are used for the treatment of seborrhoeic eczema. These can be combined with a topical antimycotic ointment, as necessary. In very severe cases, experimental treatment with systemic antifungal medication, such as 50 to 100 mg fluconazole once daily for 2 to 4 weeks, can be given in addition to topical treatment Seborrhoeic Dermatitis in the Adult.
In blepharitis caused by rosacea, the eyelid margin should be cleansed daily. A warm, moist compress should be kept on the eyelid for 5 to 10 minutes, and the entire eyelid margins then cleansed by gently pressing with a cotton swab at the eyelash roots. This can be combined with systemic tetracycline, as necessary, such as 150 mg doxycycline once daily for a total of 2 weeks, and subsequently 50 mg once daily for a total of 3 months Rosacea.
For periocular dermatitis, systemic tetracycline should be given, e.g. 500 mg once or twice daily for 1 to 2 months. In mild cases, a metronidazole ointment alone may be sufficient Perioral Dermatitis.
For other types of blepharitis (e.g. purulent staphylococcal blepharitis), either topical (e.g. chloramphenicol or fusidic acid eye drops) or systemic antimicrobials (e.g. 500 mg cephalexin 3 times daily for 7 to 10 days) should be used.
Specialist consultation
Epicutaneous tests should be performed if allergic contact dermatitis is suspected.
A dermatologist should be consulted in cases of severe eyelid eczema resistant to treatment.
In severe atopic or chronic blepharitis, an ophthalmologist should be consulted.
References
Herro EM, Elsaie ML, Nijhawan RI et al. Recommendations for a screening series for allergic contact eyelid dermatitis. Dermatitis 2012;23(1):17-21. [PubMed]
Carlisle RT, Digiovanni J. Differential Diagnosis of the Swollen Red Eyelid. Am Fam Physician 2015;92(2):106-12. [PubMed]
Wolf R, Orion E, Tüzün Y. Periorbital (eyelid) dermatides. Clin Dermatol 2014;32(1):131-40. [PubMed]