Differential Diagnosis of the Swollen Red Eyelid ART PAPIER, MD; DAVID J. TUTTLE, MD; and TARA J. MAHAR, MD University of Rochester School of Medicine and Dentistry, Rochester, New York The differential diagnosis of eyelid erythema and edema is broad, ranging from benign, self- limiting dermatoses to malignant tumors and vision-threatening infections. A definitive diagnosis usually can be made on physical examination of the eyelid and a careful evalu- ation of symptoms and exposures. The finding of a swollen red eyelid often signals celluli- tis. Orbital cellulitis is a severe infection presenting with proptosis and ophthalmoplegia; it requires hospitalization and intravenous antibiotics to prevent vision loss. Less serious conditions, such as contact dermatitis, atopic dermatitis, and blepharitis, are more common causes of eyelid erythema and edema. These less serious conditions can often be managed with topical corticosteroids and proper eyelid hygiene. They are differentiated on the basis of such clinical clues as time course, presence or absence of irritative symptoms, scaling, and other skin findings. Discrete lid lesions are also important diagnostic indicators. The finding of vesicles, erosions, or crusting may signal a herpes infection. Benign, self-limited eyelid nodules such as hordeola and chalazia often respond to warm compresses, whereas malignancies require surgical excision. (Am Fam Physician 2007;76:1815-24. Copyright © 2007 American Academy of Family Physicians.) ▲ Patient information: atients with eyelid erythema and Contact dermatitis can be classified as A handout on herpes zos- edema often present first to the allergic or irritant. The presenting features of ter ophthalmicus is avail- able at http://familydoctor. family physician. Cellulitis may be these types often are not readily distinguish- org/745.xml. suspected in patients with a red, able, but patients with irritant contact der- P swollen eyelid, although dermatitis is a more matitis often present with greater burning common cause. The differential diagnosis of and stinging compared with the characteris- eyelid edema is extensive, but knowledge of tic pruritus of allergic contact dermatitis.1,7,8 the key features of several potential causes can assist physicians in diagnosing this con- ETIOLOGY dition (Table 1). Particular attention must Contact dermatitis of the eyelid is medi- be paid to visual clues, exposures, and other ated by a type IV hypersensitivity reaction historical factors in the work-up of patients in allergic contact dermatitis and by direct with eyelid edema (Figure 11,2). toxic effect in irritant contact dermatitis.1 It is more often caused by a product applied Contact Dermatitis to the hair, nails, or face than by products Contact dermatitis is the most common applied directly to the eyelids.7 Table 2 lists cause of cutaneous eyelid inflammation.3-6 common exposures that can cause contact Eyelid skin is especially vulnerable to irri- dermatitis.8-23 tants and allergens because of its thinness and frequent exposure to chemicals via DIAGNOSIS direct application or contamination from A careful history of exposure to agents known fingers and hands.3,7 As one of the most sen- to cause eyelid contact dermatitis should be sitive areas, eyelid skin may be the initial or elicited. The patient should be asked about only presenting area with signs of contact his or her occupation, hobbies, and cosmetic dermatitis, while other areas of the body use (including non-eye cosmetics, new prod- remain unaffected by the same exposure.7 ucts, and refills of a previously used product, Downloaded from the American Family Physician Web site at www.aafp.org/afp. Copyright © 2007 American Academy of Family Physicians. For the private, noncommercial use of one individual user of the Web site. All other rights reserved. Contact [email protected] for copyright questions and/or permission requests. Swollen Red Eyelid Table 1. Causes of Eyelid Erythema and Edema: Distinguishing Features and Treatments Condition Signs and symptoms Treatment Conditions typically presenting bilaterally Angioedema Often, but not always bilateral Often self-limited; avoid inciting agents Abrupt onset over minutes to hours; Emergency medical attention is required in patients with upper airway may follow an exposure obstruction; administer 0.3 mg of intramuscular epinephrine Scaling usually absent Mild cases may benefit from oral antihistamines and/or glucocorticoids: Diphenhydramine hydrochloride (Benadryl), 25 to 50 mg three or four times daily (dosage for children: 4 to 6 mg per kg per day, in three or four divided doses) Loratadine (Claritin), 10 mg daily (dosage for children two to five years of age: 5 mg daily) Prednisone, 0.5 to 1.0 mg per kg per day, then taper after three or four days Atopic Fine scaling usually present Oral antihistamines (see above) dermatitis Less edema than with contact Topical corticosteroids: dermatitis Desonide (Tridesilon) 0.05% Other signs of atopic dermatitis may Alclometasone dipropionate (Aclovate) 0.05% twice daily for five to be present 10 days Family or personal history of allergic Second-line treatments: rhinitis or atopic dermatitis Tacrolimus (Protopic) 0.1% ointment twice daily Pimecrolimus (Elidel) 1% cream twice daily Blepharitis Yellow scaling at eyelid margins Local measures: eyelid massage, warm compresses, and gentle Patients may have pruritus or burning scrubbing twice daily with a cotton swab and 1:1 solution of dilute Less edema than with cellulitis or baby shampoo or commercially available eyelid cleanser contact dermatitis; edema more For staphylococcal infections, bacitracin or erythromycin ointment to prominent at eyelid margin eyelid margins at bedtime for one to two weeks For meibomian gland dysfunction, may add tetracycline, 250 mg four times daily, or doxycycline (Vibramycin), 100 mg three times daily, then taper after four weeks Contact Onset follows exposure Avoid inciting agents dermatitis Pruritus in allergic contact dermatitis; For allergic dermatitis, desonide 0.05% or alclometasone dipropionate burning or stinging in irritant 0.05% cream or ointment twice daily for five to 10 days contact dermatitis For irritant dermatitis, cool compresses and a petroleum-based Minimal scaling emollient applied at bedtime Edema may be profound Rosacea Telangiectasias often present Local measures as for blepharitis Onset over weeks to months Systemic tetracyclines: Eyelid changes often accompany Tetracycline, 250 mg four times daily flushing, papules, and pustules of Doxycycline, 100 mg three times daily the nose, cheek, forehead, and chin Topical metronidazole 0.75% cream (Metrocream) or gel (Metrogel) twice daily Azelaic acid gel (Finacea) twice daily Systemic Onset over weeks to months Maximize treatment of the underlying disorder processes Other cutaneous and systemic findings present continued because changes in cosmetic formulations with or without involvement of the face and are common).7 Patients with irritant contact hands.1 Examination may reveal a combina- dermatitis may have pruritus, burning, or tion of erythema, edema, and vesiculation in stinging of the eyelids and periorbital area, patients with acute dermatitis, or scaling and 1816 American Family Physician www.aafp.org/afp Volume 76, Number 12 ◆ December 15, 2007 Swollen Red Eyelid Table 1 (continued) Condition Signs and symptoms Treatment Conditions typically presenting unilaterally Cellulitis* Often presents with severe edema, deep Suggested oral regimen for patients with preseptal cellulitis only†: violaceous color, and pain Amoxicillin/clavulanate (Augmentin), 875 mg twice daily or Onset over hours to days 500 mg three times daily (dosage for children older than three History of preceding trauma or bite months: 40 mg per kg three times daily; dosage for children younger than three months: 30 mg per kg every 12 hours) Suggested intravenous regimens: Ampicillin/sulbactam (Unasyn), 1.5 to 3 g every six hours (dosage for children: 300 mg per kg daily, divided every six hours) Ceftriaxone (Rocephin), 1 to 2 g daily or divided every 12 hours (dosage for children: 50 to 75 mg per kg daily, divided every 12 hours) Parenteral antibiotics are often given for seven days in orbital cellulitis; transition to oral antibiotics if clinical improvement is noted after one week, to complete a total treatment course of 21 days Herpes simplex Vesicles often present Often self-limited; use supportive measures such as compresses Pain or burning may be present Topical bacitracin may help prevent secondary infection Onset over hours to days Recurrent cases can be treated with long-term suppressive therapy: Acyclovir (Zovirax), 400 mg twice daily Valacyclovir (Valtrex), 500 mg to 1,000 mg daily Famciclovir (Famvir), 250 mg twice daily Herpes zoster Older adults Cool compresses ophthalmicus Vesicles often present Acyclovir, 800 mg five times daily for seven to 10 days; Pain or burning valacyclovir, 1 g three times daily for seven days; or Onset over hours to days famciclovir, 500 mg three times daily for seven days Early initiation of tricyclic antidepressants (desipramine [Norpramin], 25 to 75 mg at bedtime) may inhibit postherpetic neuralgia Patients may require additional treatment for complications such as keratitis and glaucoma Tumors Older adults Depending on tumor type, Mohs micrographic surgery or wide Insidious onset local excision Typically painless nodule *—Alternative empiric regimens may be necessary in patients with community-acquired methicillin-resistant Staphylococcus