Dear Editor,
Among the etiologies of eyelid eczema, allergic contact dermatitis (ACD) is the most frequent one. The allergens, in these cases, can be present in products applied directly to the eyelids (e.g.: eye drops), to other areas, such as the scalp (e.g.: shampoos) and nails (e.g.: nail polish), or even dispersed in the environment (e.g.: perfumes acting as aeroallergens).11 Amin KA, Belsito DV. The aetiology of eyelid dermatitis: a 10-year retrospective analysis. Contact Dermatitis. 2006;55:280-5.
2 Lewallen R, Clark A, Feldman SR. Clinical Handbook of Contact Dermatitis ‒ Diagnosis and Management by Body Region. Boca Raton FL: Taylor e Francis Group; 2015.
3 Landeck L, John SM, Geier J. Periorbital dermatitis in 4779 patients - patch test results during a 10-year period. Contact Dermatitis. 2014;70:205-12.
4 Feser A, Plaza T, Vogelgsang L, Mahler V. Periorbital dermatitis ‒ a recalcitrant disease: causes and differential diagnoses. Br J Dermatol. 2008;159:858-63.-55 Guin JD. Eyelid dermatitis: a report of 215 patients. Contact Dermatitis. 2004;50:87-90.
There are few Brazilian studies on the subject and thus, the importance of the present study, which aimed to determine demographic and clinical characteristics of patients with eyelid eczema undergoing patch testing at a reference service between 2004 and 2018, their etiologies and allergens.
Data from medical records of patients with eyelid eczema who were submitted to patch testing during the study period were retrospectively assessed. These tests followed the application and reading methodology recommended by the International Contact Dermatitis Research Group. According to the anamnesis, the allergens used in the tests were: Brazilian standard battery (30 substances/FDA-Allergenic, RJ, Brazil), cosmetics (10 substances/FDA-Allergenic, RJ, Brazil), Latin American battery (24 substances/Chemotechnique Diagnostics, Malmo, Sweden), also called regional or extended standard, hair battery (15 substances/IPI ASAC, SP, Brazil) and, when possible, individual allergens and the patient's own products. The Finn Chamber (Smart Practice, USA) or Allergo Chamber (Neoflex, São Paulo, Brazil) were used in the tests.
The study included 228 patients, 204 (89.5%) of which were females and 24 (10.5%) males. The higher proportion of women is consistent with the literature and justified by the higher use of cosmetic products that cause palpebral ACD in the female population.66 Wolf R, Orion E, Tüzün Y. Periorbital (eyelid) dermatides. Clin Dermatol. 2014;32:131-40.,77 Assier H, Tetart F, Avenel-Audran M, Barbaud A, Ferrier-le Bouëdec MC, Giordano-Labadie F, et al. Is a specific eyelid patch test series useful? Results of a French prospective study. Contact Dermatitis. 2018;79:157-61.
The mean age of patients was 45 years. Regarding ethnicity, 114 (50%) were white, 42 black (18%), 68 were brown (30%), and 4 were yellow (1.75%). Regarding atopy, 91 (39.9%) had a personal history and 66 (28.9%) had a family history of atopy. The time lenght of the dermatosis evolution had a median value of 12 months.
The final diagnosis of the analyzed patients was ACD in 139 cases (61%), atopic dermatitis (AD) in 29 (12.7%), unclear in 28 (12.3%), irritant contact dermatitis in 18 (7, 9%), overlapping of ACD and AD in seven (3.1%) and other diagnoses in seven (3.1%).
Regarding the clinical aspects, 148 (64.5%) had eczema lesions in other regions of the body in addition to the eyelids, such as other areas of the face in 118 (51.8%), arms in 82 (36%), hands in 52 (22.8%), legs in 47 (20.6%), trunk in 43 (18.9%) and scalp in 24 (10.5%). The higher proportion of involvement in other areas of the face and upper limbs can be explained by the greater use of cosmetic products in these regions (Figs. 1 and 2).
Of the 228 cases, 183 (80.3%) had at least one positive patch test. However, after establishing the relevance, this number decreased to 147 patients (64.4%), of which 94 (41.2%) had just one relevant positive result, 31 (13.6%) had two, and 22 (9 .6%) had three or more. In a similar French study; 56.4% had at least one relevant positive test result.77 Assier H, Tetart F, Avenel-Audran M, Barbaud A, Ferrier-le Bouëdec MC, Giordano-Labadie F, et al. Is a specific eyelid patch test series useful? Results of a French prospective study. Contact Dermatitis. 2018;79:157-61.
The use of the Brazilian standard and cosmetics batteries in patch tests made it possible to diagnose the vast majority of ACD cases (84.3%). However, it is noteworthy that the use of other batteries was adopted in the service only from 2014 onwards.
Among the patients with a final diagnosis of ACD, the main etiologies were nail polish in 53 (36%), topical medications in 40 (27.2%), unspecified cosmetics in 36 (24.5%), hair dyes in 20 (13.6%), metals in 23 (15.6%), rubber in ten (6.8%) and shampoos in six (4%). The relevant allergens are shown in Table 1.
Literature studies show that cosmetics are the main cause of eyelid ACD, most often due to fragrances and preservatives, with the main allergens being: sodium gold thiosulfate, perfume mix, balsam of Peru, and nickel sulfate.66 Wolf R, Orion E, Tüzün Y. Periorbital (eyelid) dermatides. Clin Dermatol. 2014;32:131-40.,88 Rietschel RL, Warshaw EM, Sasseville D, Fowler JF, DeLeo VA, Belsito DV, et al. Common contact allergens associated with eyelid dermatitis: data from the North American Contact Dermatitis Group 2003-2004 study period. Dermatitis. 2007;18:78-81. Thus, the present sample is compatible with the literature, with cosmetics also being the main etiology.
The toluene-sulfonamide-formaldehyde resin present in nail polish was the most common relevant allergen among those analyzed. It is a substance responsible for giving resistance and shine to nail polish. As the habit of using nail polish is common in our country, this allergen causes sensitization in a significant portion of the population, with values higher than those found in other countries.66 Wolf R, Orion E, Tüzün Y. Periorbital (eyelid) dermatides. Clin Dermatol. 2014;32:131-40.,99 Herro EM, Elsaie ML, Nijhawan RI, Jacob SE. Recommendations for a screening series for allergic contact eyelid dermatitis. Dermatitis. 2012;23:17-21.
Another common allergen among ACD cases was paraphenylenediamine, found in most permanent hair dyes. Interestingly, only seven of the 21 patients with positive tests relevant to this allergen had concomitant lesions on the scalp, showing that patients with ACD caused by hair dye may present with eczema on the eyelids only, other areas of the face, and the cervical region.1010 Ojo EO, Gowda A, Nedorost S. Scalp Dermatitis in Patients Sensitized to Components of Hair Products. Dermatitis. 2019;30:264-7.
The preservatives Kathon CG and formaldehyde as well as fragrances are also observed on sensitizers present in cosmetic products in cases of eyelid ACD.66 Wolf R, Orion E, Tüzün Y. Periorbital (eyelid) dermatides. Clin Dermatol. 2014;32:131-40.,88 Rietschel RL, Warshaw EM, Sasseville D, Fowler JF, DeLeo VA, Belsito DV, et al. Common contact allergens associated with eyelid dermatitis: data from the North American Contact Dermatitis Group 2003-2004 study period. Dermatitis. 2007;18:78-81.,99 Herro EM, Elsaie ML, Nijhawan RI, Jacob SE. Recommendations for a screening series for allergic contact eyelid dermatitis. Dermatitis. 2012;23:17-21.
The allergen with the highest exclude positivity in the analyzed tests was nickel sulfate, although its frequency was lower among the relevant positive tests (15.6% of eyelid ACD cases). They can be a cause of eyelid ACD due to their presence in metal products (e.g., eyelash curlers) and as makeup contaminants. The accidental transfer of nickel on contact from the hands to the eyelids is also common.88 Rietschel RL, Warshaw EM, Sasseville D, Fowler JF, DeLeo VA, Belsito DV, et al. Common contact allergens associated with eyelid dermatitis: data from the North American Contact Dermatitis Group 2003-2004 study period. Dermatitis. 2007;18:78-81.,99 Herro EM, Elsaie ML, Nijhawan RI, Jacob SE. Recommendations for a screening series for allergic contact eyelid dermatitis. Dermatitis. 2012;23:17-21.
Regarding topical medications, the main allergens were neomycin and promethazine. These can cause ACD by direct contact (use of eye drops or accidental contact after application to another area) or by distant sensitization.66 Wolf R, Orion E, Tüzün Y. Periorbital (eyelid) dermatides. Clin Dermatol. 2014;32:131-40.
Seven of the cases were of occupational origin: three manicurists (caused by toluene-sulfonamide-formaldehyde resin from nail polishes and nickel sulfate from metallic instruments); one masseuse (caused by Kathon present in the massage lotion); one mason (caused by cement potassium bichromate and carba/thiuram-mix of rubber gloves); one installer of aluminum frames and one-floor installer (in both cases caused by the epoxy resin of the glues and grout).
The main limitations of the study were the use of different complementary batteries and two types of chambers in the tests, which configure the non-homogeneity of technical instruments in the evaluation.
Cases related to the use of cosmetics prevailed in the study, with emphasis on nail polish, although other causes were observed. Thus, when treating patients with eyelid eczema, the investigation with patch tests is essential.
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Financial supportNone declared.
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Study conducted at the Dermatology Clinic, Hospital da Santa Casa de Misericórdia de São Paulo, São Paulo, SP, Brazil.
References
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1Amin KA, Belsito DV. The aetiology of eyelid dermatitis: a 10-year retrospective analysis. Contact Dermatitis. 2006;55:280-5.
-
2Lewallen R, Clark A, Feldman SR. Clinical Handbook of Contact Dermatitis ‒ Diagnosis and Management by Body Region. Boca Raton FL: Taylor e Francis Group; 2015.
-
3Landeck L, John SM, Geier J. Periorbital dermatitis in 4779 patients - patch test results during a 10-year period. Contact Dermatitis. 2014;70:205-12.
-
4Feser A, Plaza T, Vogelgsang L, Mahler V. Periorbital dermatitis ‒ a recalcitrant disease: causes and differential diagnoses. Br J Dermatol. 2008;159:858-63.
-
5Guin JD. Eyelid dermatitis: a report of 215 patients. Contact Dermatitis. 2004;50:87-90.
-
6Wolf R, Orion E, Tüzün Y. Periorbital (eyelid) dermatides. Clin Dermatol. 2014;32:131-40.
-
7Assier H, Tetart F, Avenel-Audran M, Barbaud A, Ferrier-le Bouëdec MC, Giordano-Labadie F, et al. Is a specific eyelid patch test series useful? Results of a French prospective study. Contact Dermatitis. 2018;79:157-61.
-
8Rietschel RL, Warshaw EM, Sasseville D, Fowler JF, DeLeo VA, Belsito DV, et al. Common contact allergens associated with eyelid dermatitis: data from the North American Contact Dermatitis Group 2003-2004 study period. Dermatitis. 2007;18:78-81.
-
9Herro EM, Elsaie ML, Nijhawan RI, Jacob SE. Recommendations for a screening series for allergic contact eyelid dermatitis. Dermatitis. 2012;23:17-21.
-
10Ojo EO, Gowda A, Nedorost S. Scalp Dermatitis in Patients Sensitized to Components of Hair Products. Dermatitis. 2019;30:264-7.
Publication Dates
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Publication in this collection
03 Apr 2023 -
Date of issue
Jan-Feb 2023
History
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Received
25 July 2021 -
Accepted
11 Oct 2021