A patient with a history of depression, taking a daily multivitamin, presents with a burning sensation, increased tearing, and swelling in the right eye, without any change in vision or recall of ocular trauma, and examination reveals a pink, irritated eye with multiple eyelashes missing and a clear conjunctiva, what is the likely diagnosis and treatment?

Diagnosis: Trichotillomania (Eyelash Pulling) with Secondary Blepharitis

The most likely diagnosis is trichotillomania (compulsive eyelash pulling) given the patient's history of depression, unilateral presentation with multiple missing eyelashes, and absence of other infectious or inflammatory signs. 1

Critical Diagnostic Reasoning

Why Trichotillomania is Most Likely

• Depression history is the key clue: Trichotillomania is strongly associated with psychiatric conditions, particularly depression and anxiety disorders 1
• Multiple missing eyelashes without other findings: The examination shows missing lashes but a clear conjunctiva, which is inconsistent with infectious blepharitis that would typically show more debris, crusting, or collarettes 2, 1
• Unilateral presentation: While blepharitis can be asymmetric, the strictly unilateral nature with focal lash loss raises concern for either trichotillomania or malignancy 1

Critical Red Flag: Rule Out Sebaceous Cell Carcinoma

Any chronic, unilateral blepharitis unresponsive to standard therapy mandates full-thickness eyelid biopsy to exclude sebaceous cell carcinoma, which can be vision-threatening and life-threatening. 1

Look specifically for:

• Focal lash loss in a specific area 1
• Loss of normal eyelid margin anatomy 1
• Nodular masses or ulceration 1
• Marked asymmetry or resistance to therapy 1

Differential Diagnosis to Consider

Demodex Blepharitis

• Look for cylindrical dandruff (pathognomonic sleeves at eyelash base) 1
• Epilate 3-4 eyelashes and examine microscopically for mites 1
• More common in elderly patients and typically bilateral 1
• This patient lacks cylindrical dandruff, making Demodex less likely 1

Seborrheic Blepharitis

• Characterized by scaling, flaking, and dry skin along the eyelid margin 1
• 95% have seborrheic dermatitis elsewhere on the body 1
• Presents with collarettes at the base of eyelashes 2, 1
• The clear conjunctiva and absence of scaling make this less likely 2

Staphylococcal Blepharitis

• Shows crusting, erythema, and collarette formation at the base of cilia 2
• May cause corneal involvement with punctate erosions 2
• The absence of crusting and clear conjunctiva argue against this 2

Immediate Management Algorithm

Step 1: Psychiatric Assessment (Priority)

• Directly but sensitively inquire about eyelash pulling behavior in the context of the patient's depression 1
• Assess for other body-focused repetitive behaviors 1
• Evaluate current depression treatment adequacy 1

Step 2: Exclude Malignancy (If Any Red Flags Present)

Proceed directly to full-thickness eyelid biopsy if: 1

• Marked asymmetry persists
• Any nodular changes or ulceration present
• Focal lash loss in a specific anatomic pattern
• Unresponsive to initial conservative therapy after 2-3 weeks

Step 3: Conservative Treatment Trial

While awaiting psychiatric evaluation or if trichotillomania is confirmed:

Eyelid hygiene regimen: 2, 1

• Warm compresses to affected lower eyelid margin twice daily
• Gentle eyelid cleansing with diluted baby shampoo or commercial lid scrub
• Apply to eyelid margin, not directly to eye

Adjunctive therapy: 2

• Artificial tears 4 times daily for symptomatic relief
• Consider short course of topical antibiotic ointment (erythromycin or bacitracin) at bedtime if any secondary bacterial colonization suspected

Step 4: Ophthalmology Referral Indications

Refer immediately if: 1

• Symptoms persist beyond 2-3 weeks despite conservative management
• Any vision changes develop
• Unilateral disease remains unresponsive to initial therapy
• Any concerning features for malignancy emerge

Refer routinely if: 1

• Trichotillomania confirmed and requires specialized behavioral therapy coordination
• Chronic blepharitis develops requiring long-term management

Treatment of Confirmed Trichotillomania

Psychiatric Management (Primary Treatment)

• Cognitive behavioral therapy (CBT) with habit reversal training is first-line treatment 1
• Optimize depression treatment with psychiatry consultation 1
• Consider selective serotonin reuptake inhibitors (SSRIs) if not already prescribed 1

Ocular Protection Measures

• Long-term eyelid hygiene maintenance to prevent secondary blepharitis 2, 1
• Barrier methods during high-risk times (e.g., reading, screen time) 1
• Regular follow-up every 4-6 weeks initially to monitor lash regrowth 1

Common Pitfalls to Avoid

Most Critical Error: Missing Sebaceous Cell Carcinoma

• Never dismiss unilateral blepharitis without proper malignancy evaluation 1
• Sebaceous carcinoma can masquerade as chronic blepharitis for months to years 1
• Delayed diagnosis significantly worsens prognosis 1

Other Important Pitfalls

• Failing to recognize blepharitis as chronic condition: This requires long-term management, not cure 2, 1
• Not screening for underlying psychiatric conditions: Depression and anxiety are strongly associated with trichotillomania 1
• Treating with antibiotics alone: Without addressing the underlying pulling behavior, lash loss will continue 1
• Not evaluating for Demodex when cylindrical dandruff present: This requires specific tea tree oil-based treatment 1

Expected Clinical Course

If Trichotillomania

• Lash regrowth takes 6-8 weeks minimum after cessation of pulling 1
• Requires ongoing psychiatric management for underlying depression 1
• May have relapses during stress periods 1

If Secondary Blepharitis Develops

• Chronic condition with exacerbations and remissions 2
• Requires indefinite maintenance therapy with eyelid hygiene 2, 1
• Without maintenance, symptoms typically recur 2