Benign Skin Problems of the Eyelids

Essentials

• Eczemas belong to the most common causes of eyelid skin problems.
• Keep in mind eyelid eczema as a factor that may either aggravate symptoms of dry eyes or cause irritation symptoms of the eyes.
• 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.
• Rosacea may be an underlying cause of eye and eyelid symptoms.
• Keep in mind also the possibility of irritant contact dermatitis or allergic contact dermatitis (cosmetics, skin care products, eye drops).

Aetiology

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 determination of specific IgE antibodies or prick testing. These 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)
• The skin of the eyelids is particularly sensitive to the adverse effects of topical glucocorticoid ointments (telangiectasis, atrophy, increased intraocular pressure, cataract). The most important eye-related adverse effect is elevation of intraocular pressure (glaucoma). High-potency glucocorticoid ointments must not be applied to the facial area. Even mild (class I) glucocorticoid ointments should not be used as a continuous treatment, but there should be adequate breaks between courses.
• Intermittent courses of 1-2 weeks are safe in terms of intraocular pressure. With glucocorticoid eye drops, intraocular pressure typically rises after 3-6 weeks of use and returns to the earlier level in about 2 weeks after discontinuation. The rise in pressure caused by ointments is usually slower.
• The risk of a glucocorticoid response is increased if the patient has glaucoma, or if a glucocorticoid has previously raised intraocular pressure.
• If the patient needs repeated courses in a short time, or has pre-existing glaucoma, chalcineurin inhibitor creams are probably the first choice (e.g. tacrolimus 0.03% ointment).
• In unclear cases, or if glucocorticoid creams need to be used for a longer period or more frequent periods, an ophthalmologist's assessment and/or measurement of intraocular pressure (e.g. by an optician or optometrist) is recommended.
• 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 2-3 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 100 mg itraconazole 2 tablets once daily (a course of 7 days), can be given in addition to topical treatment. Interactions with other drugs must be checked Seborrhoeic Dermatitis in the Adult.
• Mild topical glucocorticoids and topical calcineurin inhibitors are highly effective in the treatment of psoriasis. There is also evidence for the efficacy of calcitriol ointment Psoriasis.
• 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 50-100 mg doxycycline once daily for a total of 6-12 weeks Rosacea.
• For periocular dermatitis, systemic tetracycline should be given, e.g. 250 mg twice daily as a course of 1-3 months in total. 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.