Pearls for the Diagnosis and Management of Eyelid and Lip Dermatitis With sensitivity to diagnostic clues and initiation of appropriate therapeutic strategies, clinicians can eliminate irritant dermatitis of the lips and eyelids.

By Matthew J. Zirwas, MD

mong suspected irritant and allergic reactions localized to the face, involve- ment of the eyelids and lips may be Aamong the most common, most chal- lenging, and most frustrating presentations. Typical tools, such as standard patch-testing with the T.R.U.E. Test (Allerderm), may not prove particularly useful in these presenta- tions, since in my experience it often does not identify a relevant allergen. Many of these cases of eyelid and lip dermatitis appear to be caused by exposure to irritants, and successful management typically

requires a methodical review of products Photos courtesy of Matthew J. Zirwas, MD used and in some cases a lengthy trial-and- Irritant eyelid dermatitis. error process to uncover the offending agent. about the history of the current presentation, previ- ous experiences of irritation and inflammation of Initial Steps the eyelids, lips, or other areas, and, of course, his- When a patient presents with eyelid and lip der- tory of allergy or irritant reactions in general. matitis, evaluation begins with careful questioning Occasionally, a patient with a known allergy or his-

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Table 1. Eyelid Dermatoses: Principles and Management Lip Dermatitis In my clinical experience, a few particular agents are Seborrheic Dermatitis of the Eyelids commonly implicated in lip dermatitis. These include • Exclude other diagnoses as much as possible. cinnamon and mint flavored toothpastes, whose fla- • Check retroauricular areas; supports diagnosis. vorings may act as non-immune contact urticants. • Treat with corticosteroidssteroids, antifungals, TCIs, Advise patients to avoid these flavored toothpastes as appropriate. and to instead use children's fruit or bubble gum fla- • Wash face with dandruff shampoo. vored toothpastes. Lip cosmetics are obviously frequently implicated. Atopic Dermatitis and Lichen Simplex Chronicus of the Eyelids On review of the products being used by patients, • Patients are sually are an obvious atopic, although not neces- “plumpers” are frequently noted, as are glosses. I sarily affected by atopic dermatitis. advise patients that the more liquid, shinier, and • Most patients have seasonal allergies. glossier a product is, the more likely it is to be an • LSC Favors central eyelid, but can affect entire upper and offending irritant. Instead of these products, patients lower lids. should opt for “waxy” lip cosmetics. • Consider oral or ophthalmic antihistamines (Zaditor, ketotifen There is a remarkable variety of products sold for fumarate opthalmic solution, Novartis). use on the lips for women and for men, including col- ored lipsticks, lip glosses, lip balms, etc. Given the Irritant Eyelid Dermatitis Treatment Principles number of products available, identifying the offend- • If chronic/continuous use a TCI. ing agent in any particular case may become time con- • For short-term or intermittent therapy, steroids may be used suming. Once potentially causative agents are identi- with caution. Excess use is associated with risk of glaucoma fied, patients must completely avoid those, and any • Rinse eyelids very well after washing face. similar, products. It often takes at least six weeks of • Wash face with CeraVe or Cetaphil after shampooing. complete avoidance before the patient begins to see • Consider anti-itch or barrier repair moisturizers. resolution of the dermatitis. During this period, and for several months after resolution, the lips continue tory of irritant reaction to a specific agent may be to be extremely susceptible to irritation, and even a unwittingly applying that agent to the face. Also single application of a “plumper” or a liquid, glossy, or question patients about a history of atopic disease, shimmery product can lead to a relapse. including but not limited to atopic dermatitis, In addition to avoidance strategies, treatment strate- and/or a history of psoriasis. As discussed below, gies may be implemented to help quell the dermatitis this information may be relevant to the differential and improve patient comfort. Patients insistent on diagnosis of eyelid dermatitis. using lip coloring agents may be advised to use solid Frequently, despite taking an extensive history, a lipsticks in traditional colors, which tend not to be irri- specific cause of the dermatitis is not readily appar- tating. To provide moisture to the lips and support ent. A patch test series is indicated in most patients. healing, patients may apply unscented petroleum jelly However, as noted above, standard testing frequent- or Biafine (Ortho Dermatologics). The latter is desig- ly does not reveal relevant positive patch reactions, nated for use in wound healing and burn management and even extended testing with cosmetic series is but has provided good results in a number of my lip often unrevealing. Therefore, a period of avoidance dermatitis patients. Also, advise patients to minimize of suspected allergens and irritants becomes neces- lip licking. One pearl when dealing with suspected sary. Without avoidance of offending agents, long- lip-lickers - do not ask about licking at the onset of the term clearance is impossible. However, sympto- visit, instead simply observe the patient during the matic treatments are available for both lip and eye- interview. I have observed many patients who lick lid involvement. their lips frequently during the interview, but are

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unaware of the habit and deny it cus, most commonly related to when asked, even after I have ocular pruritus related to allergies watched them lick their lips over to airborne allergens, such as a dozen times during a 30 minute pollen, dust mite, or mold. interview! If the patient has a history of For short-term management of atopic dermatitis or current lip dermatitis, patients may apply eczema at another body site, con- a low-potency topical corticos- sider the likelihood that the eye- teroid. For more long-term med- lid dermatitis is actually atopic ical treatment, consider Protopic dermatitis. ointment (tacrolimus, Astellas Erythema and scale and/or Pharma). retroauricular involvement absent any significant edema is sugges- Eyelid Dermatitis tive of psoriasis or seborrheic der- The approach to eyelid dermati- Photos courtesy of Matthew J. Zirwas, MD matitis (SD) affecting the eyelids. tis may be somewhat more Lip dermatitis. The top patient tested positive Involvement of the nasolabial complicated, primarily due to for a fragrance allergy that was not relevant. folds and/or the presence of scale The patient on the bottom had no patcth test the number entities in the dif- on the eyebrows is more likely reactions. ferential diagnoses that must be with SD. considered. Common conditions include: In the event that any of these primary etiologies • Allergic contact dermatitis is suspected, appropriate targeted therapy should be • Irritant contact dermatitis/psoriasis implemented (see Table 1). Following are recom- • Seborrheic dermatitis mendations regarding the management of allergic • Atopic dermatitis and irritant etiologies. • Lichen Simplex Chronicus Asymmetric Eyelid Dermatitis: Allergic. As Certain characteristics of the presentation may noted, asymmetrical eyelid dermatitis is likely a point to one of these diagnoses over another. For sign of a reaction to a transferred agent-usually one example, asymmetrical involvement may indicate initially or primarily applied to the hands. As such, an ectopic allergic or irritant contact dermatitis due causative agents may include: nail polish containing to transference of a substance from the patient's toluene/sulfonamide formaldehyde resins; “gel hands to the eyelids. That is, rather than introduc- nails,” “solar nails,” and nail wraps containing ing an allergenic product or agent directly to the methacrylates; hand moisturizers containing lano- eyes or face through conscious application of prod- lin, methylchloroisothiazolinone/methylisothiazoli- ucts to these areas, the patient introduces the aller- none (MCI/MI), formaldehyde, fragrances, or gen to the eyelid inadvertently when touching or parabens; or hand soaps, which also may contain rubbing the eye, and if one eye is touched more fragrance, MCI/MI, formaldehyde, as well as than the other, as is usually the case, an asymmetric betaines (such as cocamidopropyl betaine or CAPB). dermatitis can result. Transference is not the sole source of allergic con- If the dermatitis spreads beyond the eyelid, it is tact reactions of the eyelids. Agents applied to the most likely an allergic contact reaction to a product face and/or-as is more common-to the hair-bearing that contacts the entire face, either via direct appli- scalp, may migrate to the eyelids and other anatomic cation to the entire face or via rinsing down over sites, producing the dermatitis. Therefore, an impor- the face, especially of shampoos. By contrast, if tant diagnostic clue, as noted above, is occurrence of involvement is limited to the medial upper eyelid, eyelid dermatitis “beyond the eyelid.” The anterior this may be an indication of lichen simplex chroni- neck is also commonly affected, as this skin has simi-

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Above: “Eyelid dermatitis” (left) that has “moved” beyond the eyelids (right). The patient had a CAPB allergy. Right: Peri-auricular scaling of seborrheic dermatitis. Photos courtesy of Matthew J. Zirwas, MD

larities to the eyelid skin in terms of thickness and er the use of corticosteroids, as these agents have folds. Patients may not complain about dermatitis of been associated with a risk of glaucoma, and that the neck or associate it with the eyelid complaint, so risk is increased with application to the ocular area. it is important during the exam to question patients For long-term consistent application, consider a about any other current “rashes” and to visualize the TCI. Sarna Sensitive Lotion (Stiefel) can be helpful neck and retroauricular areas. Commonly implicated to relieve itch and it suitable for application to the products include soaps and shampoos containing eyelids. CeraVe (Coria) or EpiCeram (Promius) betaines, fragrance, formaldehyde, MCI/MI; hair dyes creams may be applied daily, as well. Several pearls containing para-phenylenediamine (PPD); and/or rub- related to the TCIs are useful—the burning sensa- ber in make-up applicators. Make-up itself is rarely a tion associated with these agents has been shown to source of allergic reactions, but is a frequent source be due to substance P release, so when describing it of irritant reactions, especially if the make-up is sev- to patients, it can be helpful to explain that the sen- eral months old. sation may be similar to the sensation that occurs Irritant Eyelid Dermatitis. Given the number of on the tongue when a hot pepper is eaten. Also, it differential diagnoses and potential sources of aller- has been my experience that patients who experi- gen exposure, the diagnosis of irritant eyelid der- ence burning are more consistent responders to matitis largely becomes one of exclusion. In addi- TCIs than those who do not experience burning. tion to visible erythema and the typical complaint Finally, given that the burning is due to substance P of itch, the patient may describe the eyelid as burn- release and that it ceases when substance P deple- ing, tight, or irritated. tion occurs, the burning typically resolves more Commonly implicated agents include: shampoos, quickly (within 3-4 days) if the patient applies the volatile solvents in mascara, facial soaps, antioxi- TCI at least twice daily, as opposed to once a day, dants in “creamy” eye make-up, and/or abrasive which may not be frequent enough to lead to sub- powders. Irritant eyelid dermatitis tends to be stance P depletion. chronic, as irritant-containing products like sham- Obviously, patients must avoid known or sus- poos and soaps are usually introduced daily or pected irritants. Instruct affected individuals to multiple times per week and may be retained in the wash their face and neck with a gentle cleanser eyelid fold. after shampooing in order to help prevent any irri- Treatment options for eyelid dermatitis include tant from remaining in contact with the skin. A few short-term topical corticosteroids or topical cal- important principles guide management of eyelid cineurin inhibitors (TCI). Steroids should be consid- dermatitis. ■ ered for short-term or intermittent use. In the case Dr. Zirwas is on the Speaker’s Bureau for Coria of chronic or recurrent dermatitis, carefully consid- Laboratories and Astellas Pharma.

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