Purpose
To identify frequency and pattern of contact sensitization among patients with periorbital dermatitis.
Design
Cross-sectional retrospective investigation of 1247 patients referred for patch testing over a 17-year period.
Methods
Data were collected for patients undergoing patch testing to the standard and customized trays between January 1990 and December 2006 at the Massachusetts General Hospital, Contact Dermatitis Clinic. Our study group consisted of 266 patients affected by periorbital dermatitis. Findings were compared to 981 referrals without periorbital dermatitis (controls). Patch test results were read after 48 and 72 hours and classified as allergic, questionable, irritant, or negative. Statistical analyses were carried out by using χ 2 test and Fisher exact test.
Results
General epidemiologic data among periorbital dermatitis patients showed significant predominance of female gender (87.6%) and of individuals aged 40 to 59 years (45.9%). Nickel (16.5%) and fragrance mix (13.2%) were the top-ranking sensitizers. Ingredients of topical ophthalmologic products did not result in significant sensitization. Comparison of the periorbital dermatitis group to the controls did not reveal significant differences in sensitization pattern. Patch testing confirmed the likelihood of allergic contact dermatitis in 50.8% of the periorbital dermatitis patients tested.
Conclusions
Allergic contact dermatitis is a common cause of periorbital dermatitis. Patch testing should be considered in all patients with periorbital dermatitis when suspecting contact allergy in order to identify and avoid offending allergens.
Periorbital dermatitis is an inflammatory process that is pruritic, produces significant edema and scaling of the periorbital region, and can be chronic. These characteristics can induce scratching and manipulation of the periorbital skin with possible sequelae including infection, disturbance in normal tearing dynamics, and possible loss of eyelashes. Etiologies include allergic or irritant contact dermatitis, atopic eczema, seborrheic dermatitis, rosacea, tinea faceii, or dermatomyositis.
Furthermore, the chronic use of topical corticosteroids to treat eczema in the periorbital skin can have serious effects such as cataract formation and glaucoma. Allergic contact dermatitis is common around the eyes. This may be related to the extremely thin nature of the periorbital skin, which facilitates penetration of potential allergens. Although allergic contact dermatitis of the periorbital area is not life threatening and affects only a small body area, it decreases quality of life through its often chronic, habitually relapsing course; its impact on esthetic well-being; and most importantly its effect on vision due to edema. Early detection and removal of the offending agent is paramount to prevent chronicity and this can be attained using patch testing as the diagnostic tool. We report a retrospective review of the positive patch tests and relevancies in 266 patients with periorbital dermatitis evaluated between January 1990 and December 2006 at a representative North American patch test clinic. Test results were compared to 981 referrals without involvement of the periorbital area.
Materials and Methods
Data were collected from charts reviewed for 1247 patients referred for patch testing. This group consisted of 266 patients with a primary complaint of periorbital dermatitis (including 166 patients with isolated periorbital dermatitis) and 981 individuals without periorbital dermatitis (controls). All individuals underwent patch testing to the standard (29 allergens) and in special cases to selected customized trays at the Massachusetts General Hospital, Contact Dermatitis Clinic between January 1990 and December 2006. Patch testing and reading was conducted by standardized technique in accordance with international recommendations, applying Finn chambers (Epitest Ltd Oy, Tuusula, Finland) affixed with Scanpor tape (Norgesplaster A/S, Vennesla, Norway) to the upper back. Allergens were purchased from Hermal (Reinbek, Germany). Tests remained in place for 48 hours and test sites were initially evaluated after 48 and 72 hours and in a few cases again at 96 hours and/or 7 days following placement. In this analysis only 48- and 72-hour readings were included. In selected cases adjusted patch test methods were applied on stripped skin to increase the test sensitivity. Those results were not included in this analysis. All interviews and interpretations of patch test reactions over the whole study period were performed by a single observer (E.G.). Positive patch tests reactions were graded according to international guidelines as + (infiltrated erythema, nonvesicular), ++ (edematous or vesicular), or +++ (bullous and/or erosion). Ambiguous or irritant reactions were considered negative. Relevance of positive results was determined by assessment of past history of contact with the allergen and whether expressed symptoms were consistent with the clinical picture and history. Probable, possible, and certain relevance were pooled under “relevant” while past, unknown, and not applicable were considered as “nonrelevant.” Patients were instructed about possible allergen sources and how to avoid them. A follow-up visit was used to evaluate outcomes. The absence of further skin complaints and a partial or complete recovery when strictly avoiding the positive-tested allergens was confirmatory for the diagnosis of allergic contact dermatitis. A re-challenge to the contact allergens was not performed. Further common diagnoses of periorbital skin changes in case of negative or nonrelevant patch test results included atopic dermatitis (personal or family history of flexural eczema), irritant contact dermatitis (dermatitis at the site of contact with presence of a substance known to be an irritant), seborrheic dermatitis (papulosquamous disorder on sebum-rich hair-bearing areas), rosacea (papulopustular erythematosus, acne-like rash, associated with telangiectasia), and urticaria (transient pruritic erythematous and edematous plaques). For age-related data analysis, individuals were categorized into age groups of ≤19, 20–39, 40–59, and ≥60 years.
Data were recorded, retrieved, and evaluated using a computer database (Microsoft Access 2000, Seattle, Washington, USA). Statistical analysis was performed with SPSS 15.0 (SPSS Inc, Chicago, Illinois, USA). Frequencies were compared using the χ 2 test and Fisher exact test where appropriate. Statistical analysis was done on the 20 most frequent allergens that were found for 266 patients with periorbital dermatitis. The multiple level of significance was 0.05. To adapt for multiple testing, the level of significance for allergens tested was adjusted to α ≤ 0.003 (Bonferroni correction of factor 20).
Results
Patients patch tested for periorbital dermatitis made up 21.3% (266/1247) of investigated individuals in this 17-year period of observation. Two hundred thirty-three female patients, aged 8–78 years, and 33 men, between 17 and 79 years, were evaluated. As shown in Table 1 , predominance of female gender in the periorbital dermatitis group (87.6%) was statistically significant ( P < .005) compared to those patients tested for reasons other than periorbital dermatitis (65.3%). Also, patients referred for evaluation of periorbital dermatitis were on average statistically significantly younger than the controls. Most individuals belonged to the age group 40–59 years (45.9%), followed by 20–39 years (38.3%). Children/adolescents and older patients were infrequently seen; only 1.9% of referrals were ≤19 and 13.9% were ≥60 years respectively. At the initial visit, 15% of patients reported an atopic history, being defined as the presence of at least 1 of the following conditions: atopic dermatitis, allergic rhinoconjunctivitis, or allergic asthma. Sensitized individuals showed on average 2.0 positive reactions. Leading sensitizers were nickel sulfate, fragrance mix, cobalt chloride, balsam of Peru, and quaternium 15 ( Table 2 ). Among 20 most frequent allergens in patients with periorbital dermatitis, no statistically significant gender-related predominance was observed (data not shown). Highest relevance was evaluated for thimerosal, wool alcohols, nickel sulfate, and epoxy resin. Comparison of sensitization to common allergens among patients with periorbital dermatitis and those without did not show statistically significant differences. For the various age groups, leading allergens were the following: ≤19 years, thimerosal and fragrance mix; 20–39 years, nickel sulfate and fragrance mix; 40–59 years, nickel sulfate and fragrance mix. Individuals ≥60 showed highest sensitization rates for fragrance mix and balsam of Peru. Further details of sensitization rates are listed in Table 2 . Most common final diagnoses in patients with periorbital dermatitis and those without were allergic contact dermatitis (50.8% vs 43.4%), followed by atopic dermatitis (26.3% vs 20.0%) and atopic dermatitis with relevant allergic contact dermatitis (4.2% vs 3.2%). The concomitant diagnoses of allergic contact dermatitis and atopic dermatitis were significantly more common in the periorbital dermatitis group ( P < .05), while irritant contact dermatitis dominated in the control group (4.4% vs 0.8%; P < .005). Further common etiologies included psoriasis (periorbital group 2.3%, controls 3.2%), seborrheic dermatitis (1.4% vs 1.0%), rosacea (0.8% vs 0.7%), and urticaria (0.4% vs 1.2%). The remaining 13% of individuals evaluated for periorbital dermatitis were merged under “other diagnoses” and included less common diseases such as protein contact dermatitis, dermatomyositis and angioedema.
| Periorbital Dermatitis | 95% Confidence Interval | Controls | 95% Confidence Interval | P Value Periorbital Dermatitis vs Controls | |
|---|---|---|---|---|---|
| N | 266 | 981 | |||
| Females, n | 233 (87.6%) | (83.4, 91.3) | 641 (65.3%) | (62.3, 68.2) | <.005 |
| Average age in years | 44.0 | (38.3, 50.2) | 46.8 | (43.7, 50) | .01 |
| Atopic disposition, n | 40 (15.0%) | (11.0, 19.5) | 132 (13.5%) | (11.5, 15.8) | .507 |
| Allergen | Main Sources | Periorbital Dermatitis Sensitized, n (%) | 95% Confidence Interval | Periorbital Dermatitis Relevant Test Results in % | Controls Sensitized, n (%) | 95% Confidence Interval | P Value Periorbital Dermatitis vs Controls |
|---|---|---|---|---|---|---|---|
| Nickel sulfate | Metals, cosmetics (mascara) | 44 (16.5%) | (12.3, 21.2) | 86.4 | 138 (14.1%) | (12.2, 16.6) | .352 |
| Fragrance mix | Fragrance in cosmetics | 35 (13.2%) | (9.7, 17.8) | 54.3 | 160 (16.3%) | (14.2, 18.9) | .184 |
| Cobalt chloride, 6H 2 O | Metals | 23 (8.6%) | (5.6, 12.3) | 69.6 | 70 (7.2%) | (5.7, 8.9) | .431 |
| Balsam of Peru | Fragrance in cosmetics, creams | 19 (7.1%) | (4.3, 10.5) | 57.9 | 125 (12.7%) | (10.9, 15.1) | .01 |
| Quaternium 15 | Preservative in cosmetics | 19 (7.1%) | (4.3, 10.5) | 84.2 | 62 (6.3%) | (5.0, 8.0) | .667 |
| 4-phenylenediamine base | Hair dyes, henna paintings | 13 (4.9%) | (2.9, 8.2) | 53.8 | 34 (3.5%) | (2.5, 4.8) | .306 |
| Thiuram mix | Accelerator in rubber products | 12 (4.5%) | (2.3, 7.3) | 75.0 | 50 (5.1%) | (4.0, 6.8) | .668 |
| Colophony | Cosmetics, mascara | 12 (4.5%) | (2.3, 7.3) | 58.3 | 39 (4.0%) | (2.9, 5.4) | .724 |
| Formaldehyde | Preservative, disinfectant, antiseptic | 10 (3.8%) | (2.1, 6.8) | 80.0 | 64 (6.5%) | (5.1, 8.3) | .083 |
| Thimerosal | Preservative in vaccines, eye drops | 10 (3.8%) | (1.6, 5.9) | 90.0 | 27 (2.8%) | (1.3, 4.8) | .089 |
| Potassium dichromate | Leather, cement | 9 (3.4%) | (1.8, 6.3) | 66.7 | 36 (3.7%) | (2.7, 5.1) | .803 |
| Neomycin sulfate | Topical antibiotics | 9 (3.4%) | (1.8, 6.3) | 22.2 | 50 (5.1%) | (4.0, 6.8) | .228 |
| N-isopropyl-N-phenyl-4-phenylenediamine | Rubber products | 8 (3.0%) | (1.3, 5.4) | 62.5 | 38 (3.9%) | (2.8, 5.3) | .506 |
| Wool alcohols | Vehicle in creams, cosmetics | 8 (3.0%) | (1.3, 5.4) | 87.5 | 50 (5.1%) | (4.0, 6.8) | .142 |
| Paraben mix | Preservative in creams, cosmetics | 8 (3.0%) | (1.3, 5.4) | 62.5 | 31 (3.2%) | (2.2, 4.5) | .874 |
| Epoxy resin | Adhesives, dental material | 7 (2.6%) | (1.1, 4.9) | 85.7 | 27 (2.8%) | (1.9, 4.0) | .891 |
| Carba mix | Rubber products | 5 (1.9%) | (0.8, 4.3) | 60.0 | 29 (3.0%) | (2.2, 4.3) | .344 |
| Phenylmercuric acetate | Preservative in meds and cosmetics | 5 (1.9%) | (0.8, 4.3) | 80.0 | 25 (2.5%) | (1.7, 3.6) | .528 |
| Balsam of Tolu | Fragrance in cosmetics | 4 (1.5%) | (0.4, 3.3) | 25.0 | 25 (2.5%) | (1.7, 3.6) | .316 |
| Methylchloroisothiazolinone/methylisothiazolinone (3:1 in water) | Preservative in cosmetics, meds | 4 (1.5%) | (0.4, 3.3) | 75.0 | 17 (1.7%) | (1.0, 2.6) | 1 |
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