What causes a rash around the eye and how is it treated?

Rash Around the Eye: Causes and Treatment

The most common cause of rash around the eye is allergic contact dermatitis (74% of cases), followed by atopic eczema, seborrheic dermatitis, and infectious causes like viral or bacterial conjunctivitis—treatment depends on identifying the specific etiology through careful examination of rash characteristics, associated symptoms, and potential exposures. 1

Critical Red Flags Requiring Immediate Referral

Before proceeding with routine management, you must immediately rule out vision-threatening and life-threatening conditions:

• Mucosal involvement (mouth, genitals) with skin pain or blistering suggests Stevens-Johnson syndrome/toxic epidermal necrolysis—this requires emergency hospitalization, preferably in a burn unit 2
• Vesicular rash on eyelids with severe pain indicates varicella zoster virus (herpes zoster ophthalmicus), which can cause corneal scarring, uveitis, and retinitis—requires immediate ophthalmology referral and systemic antivirals 3
• Purulent eye discharge with periorbital rash, especially in neonates, may indicate gonococcal infection requiring immediate systemic antibiotics to prevent corneal perforation within 24-48 hours 3, 4
• Corneal involvement detected by fluorescein staining mandates ophthalmology referral 3, 4

Diagnostic Approach Based on Clinical Features

If Rash is Accompanied by Eye Discharge and Redness

Conjunctivitis with periocular involvement:

• Viral conjunctivitis presents with watery discharge, follicular reaction on tarsal conjunctiva, preauricular lymphadenopathy, and often bilateral involvement 3, 4

  • Adenoviral pharyngoconjunctival fever includes fever, pharyngitis, and bilateral conjunctivitis 3
  • Treatment is supportive only: refrigerated preservative-free artificial tears 4 times daily, cold compresses, and strict hand hygiene 4
  • Never use topical antibiotics as they provide no benefit and promote resistance 4

• Bacterial conjunctivitis presents with purulent discharge, matted eyelashes upon waking, and may be unilateral 4, 5

  • First-line treatment: topical moxifloxacin 0.5% three times daily for 5-7 days 4
  • Alternative: topical ofloxacin 0.3% four times daily for 5-7 days if cost is a concern 4

• Allergic conjunctivitis presents with bilateral itching as the predominant symptom, watery discharge, and history of atopy 4, 6

  • First-line treatment: second-generation topical antihistamines with mast-cell stabilizing properties 4
  • Adjunctive measures: cold compresses, refrigerated artificial tears, sunglasses as allergen barrier 4

If Rash is Isolated to Eyelid Skin Without Eye Discharge

Allergic contact dermatitis (most common—74% of cases):

• Look for exposure history to cosmetics, metals (nickel in eyelash curlers), topical medications including corticosteroids, eye medications, artificial nails, or nail lacquer 1
• Important pitfall: Topical corticosteroids themselves can cause allergic contact dermatitis—consider this if rash worsens with hydrocortisone use 1
• Treatment: Identify and remove the triggering allergen, use topical or oral antihistamines for pruritus 2
• Do not use topical corticosteroids empirically without establishing diagnosis, as they can worsen HSV infections and prolong adenoviral infections 2, 4

Atopic eczema:

• Often bilateral, associated with personal or family history of asthma, allergic rhinitis, or eczema elsewhere 1
• Note that 70% of atopic patients also have concurrent allergic contact dermatitis or protein contact dermatitis 1
• Treatment requires identifying and managing both components 1

Seborrheic dermatitis:

• Presents with greasy, scaly patches on eyelids, often with concurrent scalp or facial involvement 1
• Treatment: gentle eyelid hygiene, diluted baby shampoo scrubs 1

Protein contact dermatitis:

• Caused by animal dander, dust mites, or food proteins 1
• Requires both patch testing and radioallergosorbent testing for diagnosis 1
• Treatment: avoidance of identified protein allergens 1

Specific Treatment Algorithms

For Suspected Allergic Contact Dermatitis (Most Common)

1. Discontinue all potential allergens: cosmetics, eye makeup, artificial nails, topical medications applied to face/eyes 1
2. Avoid topical corticosteroids initially unless diagnosis is certain, as they can be allergens themselves 1
3. Use oral antihistamines for symptomatic relief of itching 2
4. If no improvement in 7 days or worsening occurs, refer to dermatology for patch testing 1

For Viral Conjunctivitis with Periocular Rash

1. Supportive care only: refrigerated preservative-free artificial tears 4 times daily, cold compresses 4
2. Strict infection control: handwashing with soap and water, avoid close contact for 7-14 days, discard multiple-dose eyedrop containers 4
3. Monitor for corneal involvement with fluorescein staining—if present, refer to ophthalmology 3, 4
4. Exception: If vesicular rash on eyelids suggests HSV or VZV, start topical ganciclovir 0.15% gel or trifluridine 1% solution PLUS oral antivirals (acyclovir, valacyclovir, or famciclovir) and refer immediately 4

For Bacterial Conjunctivitis with Periocular Involvement

1. Mild-moderate cases: topical moxifloxacin 0.5% three times daily for 5-7 days 4
2. If no improvement in 48-72 hours, obtain conjunctival cultures and consider gonococcal/chlamydial infection requiring systemic antibiotics 4
3. Gonococcal conjunctivitis: ceftriaxone 250 mg IM single dose PLUS azithromycin 1 g oral single dose, with daily monitoring until resolution 4
4. Chlamydial conjunctivitis: azithromycin 1 g oral single dose OR doxycycline 100 mg oral twice daily for 7 days 4

Common Pitfalls to Avoid

• Never use combination antibiotic-steroid drops (e.g., Tobradex) empirically without definitively ruling out viral conjunctivitis, as corticosteroids prolong adenoviral infections and potentiate HSV replication 4
• Do not assume all periocular rashes are allergic—always examine for eye discharge, corneal involvement, and vesicular lesions 3, 5
• Medication history within past 8 weeks is crucial—Stevens-Johnson syndrome typically occurs 1-3 weeks after drug exposure and is a medical emergency 2
• In children with gonococcal or chlamydial conjunctivitis, consider sexual abuse and document diagnosis by standard culture 4
• Topical hydrocortisone should not be used near eyes without medical supervision, and the FDA label specifically warns to avoid contact with eyes 7

When to Refer to Ophthalmology

Immediate referral is indicated for: 4, 5

• Visual loss or visual changes
• Moderate to severe pain not relieved with topical anesthetics
• Severe purulent discharge suggesting gonococcal infection
• Corneal involvement (detected by fluorescein staining)
• Vesicular rash on eyelids (HSV or VZV)
• History of HSV eye disease
• Immunocompromised state
• Lack of response to appropriate therapy within 3-4 days
• Recurrent episodes