What is the best course of treatment for a 19-year-old female with a history of sensitive skin who presents with an itchy, slightly red rash around the inner corner of her right eye?

Treatment of Periocular Itchy Rash in a 19-Year-Old with Sensitive Skin

Start with cool compresses, refrigerated preservative-free artificial tears, and a dual-action topical antihistamine eye drop such as olopatadine or ketotifen applied to the affected eye, while also considering low-potency topical hydrocortisone for the periocular skin if the rash extends beyond the conjunctiva. 1, 2

Initial Assessment and Diagnosis

This presentation is most consistent with either allergic conjunctivitis with periocular involvement or eyelid contact dermatitis. Key features to clarify:

• Location specificity: Is the redness limited to the conjunctiva or does it involve the eyelid skin? Eyelid contact dermatitis typically presents with itching, edema, and scaling of the periorbital area, particularly affecting the thin, highly permeable eyelid skin 3
• Unilateral vs bilateral: Unilateral presentation (as in this case) may suggest contact with an allergen via hand-eye contact rather than airborne allergens 3
• Associated symptoms: Check for eye discharge, photophobia, or vision changes that would suggest more serious pathology requiring urgent referral 4

First-Line Treatment Approach

For Conjunctival Involvement

• Dual-action topical antihistamines (olopatadine, ketotifen, epinastine, or azelastine) are the most effective first-line treatment, providing both immediate relief and ongoing protection with rapid onset of action 1
• Refrigerated preservative-free artificial tears to dilute allergens and inflammatory mediators on the ocular surface 1, 5
• Cold compresses to reduce inflammation and provide symptomatic relief 1, 5

For Periocular Skin Involvement

• Low-potency topical hydrocortisone (available over-the-counter) can be applied to the affected periocular skin area 3-4 times daily for patients 2 years and older 2
• The thin eyelid skin is highly susceptible to allergens, and given the patient's history of sensitive skin, this is appropriate initial therapy 3

Critical Instructions to Patient

• Avoid eye rubbing: This is crucial as rubbing can worsen symptoms and potentially lead to keratoconus, especially in patients with atopic disease 1, 5
• Identify and avoid potential triggers: Common culprits include nickel (from electronic devices with hand-eye contact), cosmetics, fragrances, preservatives in eye products, and jewelry 3
• Implement allergen avoidance: Wash hands frequently, avoid touching the eye area, consider hypoallergenic bedding, and wash clothes frequently 1, 5

Escalation Strategy if No Improvement in 48 Hours

• Add a brief 1-2 week course of loteprednol etabonate (low side-effect profile topical corticosteroid) if symptoms are inadequately controlled 1, 5
• Baseline and periodic IOP measurement plus pupillary dilation to evaluate for glaucoma and cataract if any corticosteroid is used 1, 5
• For eyelid involvement in patients 2 years or older, topical tacrolimus ointment 0.03% or pimecrolimus cream 1% can be considered for more severe cases 6, 1

Red Flags Requiring Urgent Ophthalmology Referral

• Severe pain not relieved with topical anesthetics 4
• Vision loss or significant visual changes 4
• Copious purulent discharge 4
• Corneal involvement 4
• Distorted pupil 4
• Photophobia with pain (suggesting keratitis or iritis) 4

Critical Pitfalls to Avoid

• Never use punctal plugs in allergic conjunctivitis as they prevent flushing of allergens and inflammatory mediators from the ocular surface 1, 5
• Avoid chronic vasoconstrictor use: Over-the-counter antihistamine/vasoconstrictor combinations can cause rebound vasodilation (conjunctivitis medicamentosa) with prolonged use 1
• Avoid oral antihistamines as primary treatment: They may worsen dry eye syndrome and impair the tear film's protective barrier 1, 5
• Do not use topical antibiotics: They can induce toxicity and are not indicated for allergic conjunctivitis 1

Follow-Up Timing

• Reassess in 48-72 hours if symptoms persist or worsen
• If no improvement with first-line therapy, consider patch testing to identify specific contact allergens, particularly given the unilateral presentation and history of sensitive skin 3