I have intermittent peri‑ocular dermatitis (periodic rash around the eyes); what is the likely cause and how should I treat it?

Intermittent Peri-Ocular Dermatitis: Diagnosis and Treatment

The most likely cause of your intermittent peri-ocular rash is allergic contact dermatitis from cosmetics, skincare products, or eye drops, and first-line treatment is identifying and eliminating the allergen combined with tacrolimus 0.1% ointment applied once daily to the eyelids for 2-4 weeks. 1

Most Common Causes

Allergic contact dermatitis accounts for 32-44% of peri-ocular dermatitis cases and is the single most frequent etiology. 2, 3 The intermittent nature of your symptoms strongly suggests exposure to a specific trigger rather than a chronic inflammatory condition. 4

The most common culprits include:

• Eye drops (54% of cases) – particularly preservatives like benzalkonium chloride and thiomersal 5
• Face creams and cosmetics (25% of cases) – especially fragrances, preservatives, and metals 2, 4
• Nail polish – transferred to the eyelids through rubbing or touching 4
• Jewelry – nickel from earrings or necklaces causing airborne or transfer dermatitis 3

Other important causes to consider:

• Atopic dermatitis (14-25% of cases) – more likely if you have a history of eczema, asthma, or allergies 2
• Irritant contact dermatitis (8-9% of cases) – from rubbing, harsh cleansers, or environmental factors 2
• Airborne contact dermatitis (2-10% of cases) – from pollen, dust, or aerosolized chemicals 2

Initial Management Steps

Immediately discontinue all cosmetics, skincare products, eye drops, and contact lens solutions used near the eyes. 1 This is the single most critical step for successful treatment. 1

• Apply preservative-free artificial tears for symptomatic relief while the skin heals 1
• Avoid rubbing or touching your eyes, as mechanical trauma contributes to 30% of cases 5
• Review all medications including topical corticosteroid creams, as prolonged use can paradoxically cause peri-ocular dermatitis 6

Primary Treatment

Start tacrolimus 0.1% ointment applied once daily to the external eyelids and lid margins for 2-4 weeks, which has an 89% response rate. 1, 7 This is superior to topical corticosteroids for peri-ocular use because it avoids the risks of skin atrophy, glaucoma, and cataracts. 7

Critical safety warning: Never use tacrolimus if you have a history of ocular herpes simplex or varicella zoster, as it increases susceptibility to herpes simplex keratitis. 7

• Arrange ophthalmology review within 4 weeks for all patients using tacrolimus on lid margins 1
• If no improvement after 2-4 weeks, discontinue tacrolimus and consider alternative diagnoses 1

When Tacrolimus Is Not an Option

If tacrolimus is contraindicated or unavailable, use hydrocortisone 1% cream twice daily for 2-4 weeks maximum combined with liberal emollient application. 7 This is the safest topical corticosteroid for the peri-ocular area. 7

Never use topical corticosteroids for more than 8 weeks without ophthalmology co-management due to risks of glaucoma and cataracts. 7

Identifying the Specific Allergen

Consider patch testing if symptoms persist despite eliminating suspected triggers or if the rash recurs after initial improvement. 1 The most frequently identified allergens in peri-ocular dermatitis are:

• Nickel sulfate (8.9% of tested patients) 3
• Fragrance mix (4.5%) 3
• Balsam of Peru (4.0%) 3
• Paraphenylenediamine/PPD (3.7%) – found in hair dyes and cosmetics 3
• Thiomersal (3.5%) – preservative in eye drops 3

When to Seek Urgent Ophthalmology Referral

Refer immediately if you experience any of the following: 1, 7

• Visual changes or decreased vision
• Moderate to severe eye pain (beyond mild irritation)
• Severe purulent discharge
• Corneal involvement (blurred vision, severe light sensitivity)
• Age under 7 years (children cannot reliably report symptoms)
• Symptoms requiring corticosteroids beyond 8 weeks

Common Pitfalls to Avoid

• Do not continue using suspected products "just to see" if they cause the rash – this delays healing and can worsen sensitization 1
• Avoid preserved formulations of any topical medication near the eyes, as preservatives themselves frequently cause allergic contact dermatitis 1
• Do not use fluorinated corticosteroids (betamethasone, clobetasol) on the eyelids, as they cause severe skin atrophy and can induce a steroid-dependent dermatitis 6
• Women over 40 with atopic history are at highest risk for peri-ocular dermatitis and should be especially vigilant about new products 2

Expected Timeline

• Most cases improve within 2-4 weeks of allergen elimination and tacrolimus treatment 1
• If symptoms persist beyond 4 weeks despite appropriate treatment, patch testing is indicated to identify hidden allergens 1
• Complete resolution occurs in 90% of patients once the causative agent is identified and eliminated 5