What is the likely cause and appropriate treatment for periorbital and cheek blisters and swelling in a patient who recently started nightly bilevel positive airway pressure (BiPAP) therapy and has a known adhesive allergy?

BiPAP Mask-Related Contact Dermatitis

The blisters and periorbital/cheek swelling are almost certainly caused by allergic contact dermatitis from the BiPAP mask components, particularly given the patient's known adhesive allergy—immediately discontinue the current mask interface and switch to a hypoallergenic silicone mask without adhesive components.

Diagnosis and Causation

The clinical presentation is highly consistent with allergic contact dermatitis (ACD) affecting the periorbital and cheek regions where the BiPAP mask makes direct contact. Facial complications from BiPAP therapy, including skin ulceration and eye irritation, are well-recognized complications that can be avoided by regular follow-up to assess mask fit 1.

Key Diagnostic Features Supporting ACD:

• Female patients with atopic diathesis (suggested by adhesive allergy history) have significantly increased risk for periorbital dermatitis 2, 3
• Allergic contact dermatitis is the most common cause of periorbital dermatitis (32-44% of cases), particularly in patients with known contact sensitivities 2, 3
• The temporal relationship—symptoms appearing after BiPAP initiation—strongly implicates the mask interface as the causative agent 1
• Mask components commonly contain allergens including adhesives, rubber accelerators, formaldehyde resins, and preservatives that can trigger ACD in sensitized individuals 2, 3, 4

Immediate Management Algorithm

Step 1: Discontinue Current Mask Interface

• Stop using the current BiPAP mask immediately to prevent further allergen exposure and worsening of dermatitis 1
• Do not simply adjust or refit the same mask—the material itself is likely the problem 1

Step 2: Treat Active Dermatitis

• Apply high-potency topical corticosteroid (clobetasol propionate 0.05% cream) to affected areas twice daily for 7-14 days 5
• For intact blisters: pierce at the base with sterile needle (bevel up), apply gentle pressure with sterile gauze to drain, but do NOT remove blister roof—it acts as biological dressing 1, 5
• Cleanse gently with antimicrobial solution without causing trauma 1, 5
• Apply bland emollient (50% white soft paraffin/50% liquid paraffin) to support barrier function and encourage re-epithelialization 1

Step 3: Switch to Hypoallergenic Mask Interface

• Select a mask made entirely of medical-grade silicone without adhesive components, latex, or rubber accelerators 1
• Ensure proper mask fit through careful adjustment—excessive leak or poor fit can cause eye irritation and skin complications even with hypoallergenic materials 1
• During NPPV titration, mask refit or change in mask type should be performed whenever significant unintentional leak is observed or patient complains of mask discomfort 1

Step 4: Consider Adjunctive Measures

• Add heated humidification to the BiPAP circuit to reduce nasal and facial irritation 1
• If mouth leak contributes to facial moisture/irritation, consider chin strap rather than switching to full-face mask initially (which increases facial contact area) 1
• Monitor for adequate ventilation with pulse oximetry, as mask displacement or poor fit can rapidly lead to severe hypoxemia and hypercapnia 1

Critical Pitfalls to Avoid

Do NOT apply topical corticosteroids long-term as maintenance therapy—while they provide temporary improvement, they can worsen perioral/periorbital dermatitis over time and cause steroid-induced skin atrophy 6, 7. Limit use to 2 weeks maximum for acute flares.

Do NOT simply readjust or tighten the existing mask—this will increase allergen contact and worsen the reaction. The mask material itself must be changed 1.

Do NOT use topical antibiotics like neomycin or bacitracin—these are common contact allergens themselves and can worsen ACD, particularly in sensitized patients 6, 2, 4.

Do NOT use greasy occlusive creams—these can facilitate folliculitis and worsen perioral dermatitis 6, 7.

Follow-Up and Monitoring

• Schedule follow-up within 1 week to assess dermatitis resolution and mask tolerance 1
• Serial evaluation and adjustment of NIPPV is necessary, as patient requirements change with time 1
• If dermatitis persists despite mask change, consider patch testing to identify specific allergens, as testing with patients' own products identifies additional allergens in 12.5% of cases 3, 8
• Monitor for adequate BiPAP efficacy—ensure the new mask maintains proper pressure delivery without excessive leak 1

Alternative Considerations (Less Likely)

While allergic contact dermatitis is by far the most likely diagnosis given the clinical context, if symptoms fail to resolve with mask change and topical corticosteroids, consider:

• Irritant contact dermatitis from pressure/friction (9% of periorbital dermatitis cases)—would improve with better mask fit alone 2, 3
• Airborne contact dermatitis (10% of cases)—less likely given localized distribution matching mask contact pattern 2, 3

The combination of known adhesive allergy, temporal relationship to BiPAP initiation, and distribution matching mask contact makes allergic contact dermatitis the definitive diagnosis requiring immediate mask interface change 2, 3, 4.