Atopic Dermatitis

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INTRODUCTION The eyelids can be affected by various types of dermatitis that can be difficult to diagnose.

Of these types 70% result from allergic contact dermatitis, and about 9% to 10% each from irritant contact dermatitis, atopic dermatitis, and seborrheic dermatitis. Atopic dermatitis is a chronically relapsing inflammatory skin disease. It is a genetically fixed disease that remains with the patient all their lives, whether they show symptoms or not. It occurs in approximately 2% of the population. In several large series 80% to 90% of patients with eyelid dermatitis were female. Distinct infantile, juvenile, and adult stages of the disease have been reported. Associated diffuse eczematous skin changes vary with the age of the patient and often disappear during puberty or adolescence. In the infantile stages associated manifestations include facial erythema and crusting. After age two to three years erosions, lichenification, and hyper or hypopigmentaton develop particularly on the face and flexural surface of the extremities. In adults the rash may be bright red, edematous and oozing or more chronic appearing with lichenified and hyperpigmented patches, or it may present as a mixture of both. Infectious complications are common and it has been shown that 87% of patients with atopic dermatitis harbor bacterial colonization in the conjunctival sac and eyelid margins compared to 25% in nonaffected controls. A family history of atopy manifested by atopic dermatitis, asthma, or hay fever exists in 70% of affected individuals. Eyelash length has been shown to be longer in children and adolescents with allergic diseases, including atopic dermatitis.

CLINICAL PRESENTATION Eyelid changes consist of edematous, indurated, or weeping eczematous lesions.

Pruritis aggravated by heat, sweat, or wool often leads to chronic rubbing and as a result, the eyelid skin becomes violaceous early on and hyperpigmented with time. Coalescent papules, fissures, and fine scaling may occur. If the condition becomes chronic, thickening and accentuation of normal skin lines (lichenification) can occur on the periocular skin, and scaling plaques occur predominantly on the upper eyelids. With time eversion or stenosis of the lacrimal puncta may occur and frank ectropion may be seen in severe cases. Loss of eyelashes can occur. Darkening of periorbital skin suggests the diagnosis of atopy and is frequently of cosmetic concern to patients. Secondary staphylococcal infection or colonization of the eczematous skin is common leading to chronic anterior blepharitis. Associated ocular changes include keratoconjunctivitis, chemosis, sympblepharon, corneal pannus, Tranta's dots, anterior and posterior subcapsular cataracts, and keratoconus.

Blepharitis Simplex

HISTOPATHOLOGY The histological appearance is dependent on the phase of the process. Acute lesions show spongiosis, lymphocytes, and macrophages around blood vessels of the superficial dermis, and extension of inflammatory cells into the epidermis (exocytosis). Subacute lesions exhibit irregular acanthosis, mild spongiosis, hyperkeratosis, small foci of parakeratosis, and mild exocytosis. Chronic lesions have further thickening of the epidermis, diminished spongiosis, focal parakeratosis, and dermal fibrosis from persistent rubbing. A sparse infiltrate of eosinophils is common in the dermis.

Parakeratosis And Atopic Dermatitis

DIFFERENTIAL DIAGNOSIS The differential diagnosis includes seborrheic dermatitis, lichen simplex chronics, allergic contact dermatitis, irritant contact dermatitis, urticaria, angioedema, and rosacea.

TREATMENT The "itch-scratch" cycle must be broken in order to control the dermatitis. Treatment generally relates to intensive patient education, avoidance of known exacerbating factors such as irritant exposure, emotional stress, and infection. Topical corticosteroid preparations, oral antihistamines, and use of bland emollients (Aquaphor®, white petrolatum, and absorbase) that decrease dryness (xerosis) are important. Avoidance of hot humid climates and harsh skin detergents together with frequent skin hydration with oils or creams is important to minimize flare-ups. Cool, damp compresses often aid in relieving pruritis. Periodic flare-ups are treated aggressively with low potency nonfluorinated topical corticosteroids such as hydrocortisone or dexamethasone. Secondary staphylococcal infection is treated with oral antibiotics or bland topical antibiotic ointments. Topical corticosteroids and mast cell stabilizers are often needed to control acute keratoconjunctivitis. Surgical intervention for the eyelid changes may be necessary, but is associated with an increased incidence of peri-operative complications.


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Nakata K, Inoue Y, Harada J, et al. A high incidence of Staphylococcus aureus colonization in the external eyes of patients with atopic dermatitis. Ophthalmology 2000; 107:2167-2171. Valsecchi R, Imerti G, Martino D, Cainelli T. Eyelid dermatitis: an evaluation of 150 patients. Contact Dermatitis 1992; 27:143-147. Zug KA, Palay DA, Rock A. Dermatologic diagnosis and treatment of itchy red eyelids. Surve Ophthalmol 1996; 40:293-305.

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