CASE #2: Allergic shiner

A discussion of the allergic shiner must address the intersection of two disease categories — eyelid dermatitis and atopy. Eyelid dermatitis is a very common condition, the leading causes of which are allergic contact dermatitis, irritant contact dermatitis, atopic dermatitis, seborrheic dermatitis, nonspecific xerotic dermatitis and psoriasis. Most people with eyelid dermatitis do not have a family history of atopic dermatitis.

Atopy is a combination of three conditions: allergic rhinitis, atopic dermatitis and asthma. Signs of allergic rhinitis include red, itchy and watery eyes; itchy mouth, throat, ears and face; swollen eyelids; fatigue; and the allergic shiner. Signs of atopic dermatitis include the allergic shiner; Dennie-Morgan lines around the eyes; lichenification; red to brownish-gray patches; itching; small bumps that leak fluid and crust over when scratched; and thickened and sensitive, cracked, scaly, or raw skin from scratching.24

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Approximately 50% of the individuals who develop atopic dermatitis display symptoms before the age of 1 year, and nearly 80% display symptoms within the first five years of life.

The basis of atopy is as much genetic as it is immunologic. In many cases, the skin suffers a lack of effective ceramides. That is, atopic dermatitis is often caused by a defect in filaggrin rather than a defect in the Th2 arm of the immune system.

Many of the rashes of atopic dermatitis involve rubbing, and an allergic shiner is no exception. Other areas that are frequently involved include the antecubital and popliteal fossae and the lateral ankle. The discomfort engendered by atopy has a substantial impact on patients’ quality of life. The medical history can reveal information regarding an atopic family history and the atopic progression in the child.

Avoiding medications that contain corticosteroids optimizes treatment for atopic dermatitis. Heavy and prolonged use of topical corticosteroids is suboptimal. Long-term use of even topical steroids can be linked with such side effects as skin atrophy, telangiectasia, striae, steroid-induced dermatoses, rosacea and acne exacerbation. Rarely, systemic effects include osteonecrosis, hypothalamic-pituitary-adrenal axis suppression, growth retardation and ocular problems.25

Alternatives to topical corticosteroids include the calcineurin inhibitors pimecrolimus cream or tacrolimus (Prograf) ointment. Calcineurin inhibitors should ideally be used for short periods (two to four weeks), but clinical reality often necessitates longer use. Calcineurin inhibitors also effectively and safely treat atopic dermatitis, with the most commonly observed local adverse events being skin irritation and a burning sensation.25

Recent reports note that some moisturizers can help with eyelid dermatitis and allergic shiners. These devices provide antioxidant, antiprotease and anti-inflammatory activity and assist in restoring the natural balance of lipids, one of the primary causes of the epidermal abnormalities seen with atopic dermatitis. Ceramide-hyaluronic acid emollient foam was found to be superior to pimecrolimus cream 1% in the treatment of eyelid dermatitis.25 OTC lotions and creams for treating atopic skin include EpiCeram, MimyX, Atopiclair, CeraVe, and Cetaphil.

Treatment for the rhinitis aspect of atopy requires a strategy that uses environmental control, immunotherapy, and pharmacologic therapy. Immunotherapy can be seen as potentially prophylactic, capable of altering the course of allergic rhinitis. An allergic shiner associated with allergic rhinitis will improve as the rhinitis abates.

Individuals with atopic dermatitis are at much greater risk of developing cataracts than are controls.26 The idea that steroid use causes cataracts in these patients has mostly been disapproved; the atopic genetic makeup is what leads to cataracts. Finally, there may be an association between longer eyelashes and atopic dermatitis.27

In this case, an allergist prescribed cetirizine (Zyrtec) syrup 5 mL nightly. In one month, the rash was much improved.

Noah Scheinfeld, MD, JD, is assistant clinical professor of dermatology at Columbia University in New York City, where he has a private practice. Nicholas Barnes is a fourth-year student at Dartmouth Medical School in Hanover, N.H. The authors have no relationships to disclose relating to the content of this article.


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