Early diagnosis and removal of the allergen are keys in managing ocular contact dermatitis, but an allergy a drug used to treat a chronic condition can make it difficult to discontinue or replace the offending allergic agent, a review published in Current Opinion in Allergy and Clinical Immunology explains.
Ocular allergic contact dermatitis is a common, though frequently misdiagnosed condition. Contact dermatitis includes both irritant contact dermatitis and allergic contact dermatitis, the former of which is more frequent by a 4:1 ratio. Although these conditions share many similarities, irritant contact dermatitis is caused by a local toxic reaction to an irritant — such as alkali, acid, solvent, or soap — while allergic contact dermatitis is a delayed allergen-specific type IV hypersensitivity reaction resulting from the skin touching and subsequently “reacting to a foreign substance after previous exposure and consequential immunological sensitization.”
Allergic contact dermatitis is the leading cause of allergic periorbital dermatitis. Because many ingredients in ophthalmic solutions are known irritants, it is important to differentiate between irritant and allergic responses. The most common sources of eyelid contact dermatitis are cosmetics, topical ophthalmic medications, and contact lens solutions.
Periorbital allergic contact dermatitis has been associated with multiple formulations of topical ophthalmic medications, including drops, ointments, creams, and cosmetics. Because eyelid skin is thin, it is more susceptible to the penetration and sensitization of allergens compared with other areas of the body. Compared with irritant contact dermatitis, the response of which can range from weeks to months, responses in allergic contact dermatitis occurs between 48 and 96 hours of exposure.
Periorbital dermatitis causes vary by age; in the elderly, the cause is frequently topical medications. In the young, sensitivity usually stems from cosmetics or skincare products. Dermatitis is much more common in women than in men, and 45.9% of those affected are between 40 and 59 years of age. Among children, dermatitis is the most prevalent skin disorder but literature on allergies specifically to ophthalmic drugs is scarce.
Allergic contact dermatitis manifests as inflammation, usually involving the eyelid margins, skin conjunctiva, and eyelids either in isolation or in association with chronic conjunctivitis, keratoconjunctivitis, or other systemic manifestations. Delayed treatment can result in secondary complications like tearing, ectropion, ptosis, and increased dermatochalasis. Common clinical signs also include pruritus, erythema, edema, and periorbital scaling.
When making a diagnosis, patient history remains the key to identifying the source of the inflammation. Clinicians should pay particular attention to the patient’s work environment, hobbies, frequency, and length of exposure to metals, cosmetics, or topical medications.
While ophthalmic medications may be responsible for up to 20% of allergic contact dermatitis, it can be challenging to determine which agent is responsible due to the active and inactive ingredients that have allergen capability. Patch testing remains the standard first-line diagnostic tool, but because patch testing is performed on much thicker skin compared with the eyelids, it can be difficult to isolate what might cause an ocular periorbital allergy.
A number of common drugs can cause contact allergic dermatitis. These include topical glaucoma medications (beta-blockers, alpha-adrenergic agonists, calcium anhydrase inhibitors, prostaglandin analogs, and cholingerics), mydriatics (phenylephrine), cycloplegics, antiallery medications (antihistamines, sodium cromoglycate, chlorpheniramine, and amlexanox), preservatives (ethylene diamine tetra-acetic acid, benzalkonium chloride, parabens, thimerosal, phenylmercuric salts, metabisulfites, and chlorobutanol), antimicrobials (tobramycin, neomycin, kanamycin, and gentamycin), antivirals (idoxurine and trifluridine), nonsteroidal anti-inflammatory drugs (hydrocortisone, hydrocortisone acetate, dexamethasone, prednisolone acetate, and prednisolone pivalate), and anesthetics (tetracaine, oxybuprocaine, and proparacaine).
When an allergic reaction is present, the offending agent should be removed and steroids should be utilized to manage symptoms. The goal of treatment is to minimize inflammation and to reduce both the symptoms and clinical manifestations. Patients who have progressed to chronic dermatitis and do not respond to topical or systemic steroids may be eligible for treatment with ultraviolet A or narrow-band ultraviolet B therapies, immunomodulators, or targeted biologic therapies.
“Beyond the detrimental long-term effects of dermatitis, it is important to reduce symptoms as they lead to poor compliance, followed by lower efficacy of intended treatment,” the research says. “Although therapy up to this point has been primary avoidance…the future is turning toward development of more personalized and precise options.”
Erdinest N, Nche E, London N, Solomon A. Ocular allergic contact dermatitis from topical drugs. Curr Opin Allergy Clin Immunol. 2020;20(5):528-539. doi:10.1097/ACI.000000000000067