Derm Dx: Itchy rash on the eyelid


  • Eyelid Dermatitis 1_1013 Derm Dx

  • Eyelid Dermatitis 2_1013 Derm Dx

A 74-year-old female complains of a very itchy rash on her eyelids. Her medical problems include hypertension and glaucoma. Her medications include lisinopril and prescription eyedrops.

Eyelid dermatitis broadly describes inflammation of the eyelids. It generally appears as an erythematous, edematous, pruritic rash over the upper eyelids. There are many causes of eyelid dermatitis, and the clinical features vary by diagnosis.The most common cause of eyelid...

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Eyelid dermatitis broadly describes inflammation of the eyelids. It generally appears as an erythematous, edematous, pruritic rash over the upper eyelids. There are many causes of eyelid dermatitis, and the clinical features vary by diagnosis.

The most common cause of eyelid dermatitis is allergic contact dermatitis, characterized by an eczematous eruption on the upper eyelids. Vesicles, erythema, and exudate are commonly present in the acute phase, while the eyelids may appear lichenified and scaly in the chronic phase. Purulence may be present if secondarily infected. Patients describe pruritus as the main symptom.

Allergic contact dermatitis is caused by a delayed hypersensitivity reaction mediated by T cells. Common allergens include fragrance, metals such as nickel and cobalt, and chemicals such as toslamine formaldehyde found in nail polish. Other allergens include preservatives in medications such as cocamidopropyl betaine, methylchloroisothiazoline, and mehyldibromoglutaronirile, and active ingredients such as phenylephrine hydrochloride, sodium cromoglycate, papine, and idoxuridine. Airborne agents including pollen, dander, dust mites, and chemicals are also culprits. Contact with allergens can occur from direct application to the eyelids, transfer of the substance from the hands to the eyelids, or more commonly from nail polish, hair dyes and cosmetics applied elsewhere on the body.

The initial eruption occurs 24 to 48 hours after the first contact, while the second exposure triggers a rash in 12 to 24 hours. The eruptive phase typically lasts five to seven days, then moves into the plateau phase lasting five to seven days and finally resolves over the course of another five to seven days.

Irritant contact dermatitis appears similar to allergic contact dermatitis, but may be more diffuse. The primary symptom is a burning sensation. Severity depends on the concentration of the contactant and the duration of exposure.

Atopic dermatitis is another common cause of eyelid dermatitis. The eyelids appear red, scaly and lichenified. The rash classically affects the medial upper eyelid. Pruritus is a predominant symptom and patients who chronically scratch will have post inflammatory hypo- or hyperpigmentation.

Seborrheic dermatitis causes blepharitis characterized by redness and scale at the margin of the eyelid. A clue to the diagnosis is scale and redness also present on the scalp. Patients with neurologic disorders or HIV are more susceptible to seborrheic dermatitis.

Rosacea can also affect the eyelids causing blepharitis. The heliotrope rash of dermatomyositis appears as a symmetric, violaceous eruption on the upper eyelids.

Less common causes of eyelid dermatitis include lichen simplex chronicus, viral and bacterial infections, fixed-drug eruptions, lichen planus, psoriasis, contact urticaria and photodermatitis.

Of patients with eyelid dermatitis, 90% are women. The most common causes are allergic contact dermatitis (46%-56%), irritant contact dermatitis (15%-24%) and atopic dermatitis (14%-39%).

Diagnosis & Treatment

The diagnosis is made through the history and exam. Rarely is a skin biopsy needed, and will typically show spongiosis. In cases caused by allergic contact dermatitis, patch testing may help to identify the problematic agent.

The mainstay of treatment for eyelid dermatitis is low to mid-potency topical corticosteroids. For contact dermatitis, advise patients to avoid the allergen, relieve symptoms of itching with cold compresses, and apply a low to mid-potency topical corticosteroid.

Severe cases may be treated with systemic prednisone 0.5-1.0 mg/kg/d for the first week, and then half of the original dose through the resolution phase. Caution patients against overusing topical steroids as the thin skin of the eyelids are particularly susceptible to atrophy. 

Atopic dermatitis is managed with brief periods of treatment with topical steroids, and also with topical calcineurin inhibitors. Cyclosporine ophthalmic emulsion may be tried if topical medications fail. Cromolyn sodium drops may reduce itching. Seborrheic dermatitis is treated with selenium sulfide and zinc pyrithione containing shampoos, mild steroid creams and topical calcineurin inhibitors.

Other answer choices:

Periorbital dermatitis is a variant of perioral dermatitis characterized by discrete papules and pustules on the lower eyelids and the skin surrounding the eyelids. The predominant symptom is a painful, burning sensation. It is caused by exposure to steroids either through topical creams and ointments, or contact with steroid from inhalers. Treatment includes avoiding topical steroids, protecting the skin from contact with inhaler contents, topical tacrolimus ointment 0.1% to prevent flares, and a prolonged course of a tetracycline class antibiotic.

Impetigo is a skin infection caused by Staphylococcus or Streptococcus. It begins with erythematous macules, which evolve into vesicles and pustules that then rupture. The lesions weep serous fluid, which dries into the characteristic honey colored crust. It generally does not cause edema of the eyelids. The most common organism isolated in 50% to 70% of cases is S. aureus, while the rest are infected with S. pyogenes. The infection most commonly affects children and is acquired from pets, other people or self-inoculation from areas where the organisms are carried. Treatment is with systemic and topical antibiotics.

Cellulitis is a bacterial skin infection characterized by spreading erythema and induration, which may also contain areas of purulence or necrosis. It involves the subcutaneous layer of the skin. S. pyogenes or S. aureus  are the most common causes. Treatment includes systemic antibiotics covering these organisms, with consideration given to methicillin-resistant  S. aureus coverage depending on the history.

In this case, the patient’s dermatitis cleared after a short course of prednisone. She was patch-tested and it was determined that she has a contact allergy to benzalkonium chloride, which is a preservative used in the eyedrops she uses for her glaucoma. 

Andrea N. Lambert is a senior medical student at Washington University School of Medicine in St. Louis.

Adam Rees, MD, is a graduate of the University of California Los Angeles School of Medicine and a resident in the Department of Dermatology at Baylor College of Medicine also in Houston.


  1. Beltrani VS. Eyelid dermatitis. Curr Allergy Asthma Rep. 2001;1(4):380-8.
  2. Bolognia J, Jorizzo JL, Rapini RP. “Chapter 14-Alergic Contact Dermatitis.” Dermatology. St. Louis, Mo.: Mosby/Elsevier, 2008.
  3. James WD, Berger TJ, Elston DM et al.  Chapters 5, 13 and 14. Andrews’ Diseases of the Skin: Clinical Dermatology. Philadelphia: Saunders Elsevier, 2006.
  4. Peralejo B, Beltrani V, Bielory L. “Dermatologic and allergic conditions of the eyelid.” Immunol Allergy Clin North Am. 2008;28(1):137-68, vii.
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