PracticalDermatology

Ectropion of the lower eyelids is defined by the outward turning of the eyelid margin, with progressive exposure of the tarsoconjunctival surface, resulting in ocular surface irritation, tearing, vision impairment, and decreased quality of life.^1,2 Lower eyelid ectropion is most frequently caused by involutional changes, such as increased lid laxity and disinsertion of the lower eyelid retractors, but it can also be caused by poor orbicularis oculi muscle tone (paralytic), downward pulling of the lower eyelid (mechanical), and shortening of the anterior lamella (cicatricial). Although less common, acute and chronic inflammatory skin conditions, like contact dermatitis and atopic dermatitis (AD), can induce cicatricial ectropion and cause significant discomfort.^3-5

In clinical practice, periocular dermatitis is typically associated with allergic or irritant contact dermatitis, which is often superimposed on underlying atopic dermatitis.^6,7 However, a subset of patients experience non-allergic periocular dermatitis, without any known allergen exposure; these individuals frequently report a history of atopy.^6,7 Some in the medical community have proposed the use of topical corticosteroids (TCS) to manage these patients, but these therapeutic agents have also been associated with periocular allergic dermatitis (in addition to known risks of skin atrophy, tachyphylaxis, cataracts, and glaucoma associated with chronic use) and do not directly address the underlying skin changes that result in cicatricial ectropion.^8-10

Here, we report on the efficacy of conservative, over-the-counter treatment options for cicatricial ectropion related to chronic periocular atopic dermatitis.

Case 1

An 84-year-old white female presented with a one-year history of bilateral ocular irritation and tearing. She also noted persistent itching, redness, and swelling of the eyelids. Over the course of one month, she noted significant worsening of these symptoms, with increased tearing and the lower eyelids appearing to be pulled outward. She reported a history of allergic rhinitis, with allergies to grass, pollen, and mold. She was previously diagnosed elsewhere with bacterial conjunctivitis and later allergic conjunctivitis, which was treated with topical azithromycin, ofloxacin, and ketotifen, respectively, without any improvement, and had discontinued these ocular medications. She denied any changes in cosmetic products, soaps/detergents, etc. She did not have dermatitis elsewhere.

On examination, the patient had significant eczematous changes in both upper and lower eyelids, with scaling, thickening, hyperpigmentation, and exaggerated lines across the eyelid skin (Fig. 1A). These changes resulted in anterior lamellar shortening, effectively causing cicatricial ectropion with eversion of both lower puncta as well as mild lagophthalmos on gentle lid closure (Fig. 1A-D). There was also evidence of lower eyelid laxity on snap back. Slit-lamp examination demonstrated diffuse punctate epithelial erosions bilaterally, indicative of exposure keratopathy.

Fig. 1: Case 1. External photographs of the patient’s left eye on day of presentation in frontal (A), oblique (B), and left side profile views (C) demonstrate lichenification of the eyelid skin and ectropion of the lower eyelid secondary to cicatricial anterior lamellar changes from chronic periocular atopic dermatitis. There was also mild lagophthalmos on gentle eye closure (D). Two weeks after starting topical treatment with over-the-counter occlusive ointment, there is marked improvement in the overall skin quality, eyelid malposition, and lagophthalmos (E-H).

The patient elected for conservative management and started topical periocular application of occlusive ointment to rehydrate the periocular skin. She was also started on an ocular lubrication regimen with artificial tear eye drops throughout the day and artificial tear eye ointment at nighttime. At her 2-week follow-up visit, the patient noted significant improvement in symptoms and her eyelid appearance (Fig. 1E-H). Within 1 month from treatment initiation, the patient did not require surgical intervention due to the continued improvements in eyelid skin quality and reversal of lower eyelid ectropion.

Case 2

A 78-year-old white male presented with a 3-month history of bilateral ocular irritation, redness, and itching. He reported a history of allergic rhinitis, with recent exacerbation, for which he had been taking loratadine and fexofenadine. His ocular medications included dorzolamide/timolol, latanoprost, fluorometholone, and ketorolac eye drops, but he had been using these topical agents for years, without issue. He denied any new or known exposures to other possible allergens. He also did not have dermatitis elsewhere on his body.

On examination, there were marked changes consistent with lichenification of the periorbital skin bilaterally (Fig. 2A). In addition to bilateral lower eyelid ectropion, there was also significant lower eyelid laxity with lateral canthal rounding and lagophthalmos bilaterally (Fig. 2A-D). Given the degree of ectropion, there were papillary changes of the tarsoconjunctival surface, with early keratinization of the lid margin and diffuse punctate epithelial erosions on the cornea bilaterally.

Figure 2: Case 2. External photographs of the patient’s left eye on day of presentation in frontal (A), oblique (B), and left side profile views (C) illustrate the lichenification and scaling of the patient’s periocular skin and resultant cicatricial ectropion and lagophthalmos (D). Three months after starting treatment with over-the-counter occlusive ointment, the patient had complete resolution of his localized atopic dermatitis, ectropion, and lagophthalmos (E-H).

The patient elected to begin with conservative management and started treatment with occlusive ointment over the periocular skin as well as artificial tear eye drops throughout the day and artificial tear eye ointment at night. At his 1-month follow-up, he endorsed complete resolution of his symptoms and declined any surgical intervention. At 3 months, the patient continued to demonstrate durable improvements in eyelid skin texture and complete resolution of his lower eyelid ectropion (Fig. 2E-H).

Discussion

Lower eyelid ectropion is typically caused by involutional changes in the elderly and requires surgical intervention to address the underlying age-related changes that result in eyelid malposition. In a subset of patients, periocular dermatitis superimposed on involutional changes may result in cicatricial ectropion, causing ocular irritation, tearing, exposure keratopathy, and even corneal scarring with permanent vision loss if not addressed promptly. Although allergic or irritant contact dermatitis is more commonly the culprit,^3-9 chronic AD can alter the thin lower eyelid skin sufficiently enough to cause anterior lamellar shortening and thereby cicatricial ectropion, particularly when there are preexisting involutional changes, such as eyelid laxity.

These two cases illustrate the reversibility of cicatricial ectropion related to chronic periocular atopic dermatitis with conservative topical therapy using over-the-counter occlusive ointment, such as artificial tear eye ointment, Vaseline, or Aquaphor. Rehydration with occlusive ointment restores the thin periocular skin to its previous state and can effectively reverse the eyelid malposition, obviating the need for surgery in some patients and medically optimizing the eyelids prior to surgery in others. In severe cases, topical tacrolimus can also be considered.^10-12

While treating the eyelid skin, patients should also avoid any eye rubbing and adhere to a strict ocular lubrication regimen to manage symptoms and signs of exposure keratopathy. As evidenced by these two cases, topical application of occlusive ointment can rapidly and effectively reverse lower eyelid malposition associated with chronic atopic periocular dermatitis.

Although not performed in these two patients, patch testing should be performed when allergic contact dermatitis is suspected. Patch testing may also be appropriate in cases of chronic periocular atopic dermatitis where there are persistent eyelid changes despite a fair trial of occlusive ointment. In cases of allergic or irritant contact dermatitis, avoidance of the allergen(s) should be practiced immediately, with conservative treatment of symptoms until their resolution.

In conclusion, chronic periocular atopic dermatitis can lead to changes in the thin lower eyelid skin that essentially shorten the anterior lamella and cause cicatricial ectropion, particularly when superimposed on involutional changes, such as lower eyelid laxity.

If there is concern for an allergic component, the suspected allergen should be immediately avoided, and patch testing can be performed to identify and confirm the offending agent. For localized periocular dermatitis, conservative treatment using over-the-counter occlusive ointment can directly address and effectively reverse cicatricial eyelid changes, as demonstrated in the two cases presented herein.

Contents of this paper were presented in part at the Cosmetic Surgery Forum (Cosmetic SurgeryForum.com) in Nashville, on December 3, 2021. This presentation was recognized as a top resident presentation at CSF 2021.

Financial Support: None. Conflicts of Interest: All authors declare that they have no conflicting relationships to disclose.

1. Hakim F, Phelps PO. Entropion and ectropion. Dis Mon. 2020;66(10):101039.

2. Damasceno RW, Osaki MH, Dantas PE, Belfort R, Jr. Involutional entropion and ectropion of the lower eyelid: prevalence and associated risk factors in the elderly population. Ophthalmic Plast Reconstr Surg. 2011;27(5):317-320.

3. de Groot AC, Poelhuis JW. Ectropion caused by periocular dermatitis. J Am Acad Dermatol. 2001;44(2 Suppl):385-386.

4. Mukherjee B, Giratkar S. Cicatricial ectropion due to allergic dermatitis. Oman J Ophthalmol. 2021;14(2):126-127.

5. Chisholm SAM, Couch SM, Custer PL. Etiology and Management of Allergic Eyelid Dermatitis. Ophthalmic Plast Reconstr Surg. 2017;33(4):248-250.

6. Amin KA, Belsito DV. The aetiology of eyelid dermatitis: a 10-year retrospective analysis. Contact Dermatitis. 2006;55(5):280-285.

7. Landeck L, John SM, Geier J. Periorbital dermatitis in 4779 patients - patch test results during a 10-year period. Contact Dermatitis. 2014;70(4):205-212.

8. Baeck M, De Potter P, Goossens A. Allergic contact dermatitis following ocular use of corticosteroids. J Ocul Pharmacol Ther. 2011;27(1):83-92.

9. Erdinest N, Nche E, London N, Solomon A. Ocular allergic contact dermatitis from topical drugs. Curr Opin Allergy Clin Immunol. 2020;20(5):528-538.

10. Freeman AK, Serle J, VanVeldhuisen P, et al. Tacrolimus ointment in the treatment of eyelid dermatitis. Cutis. 2004;73(4):267-271.

11. Rikkers SM, Holland GN, Drayton GE, Michel FK, Torres MF, Takahashi S. Topical tacrolimus treatment of atopic eyelid disease. Am J Ophthalmol. 2003;135(3):297-302.

12. Katsarou A, Armenaka M, Vosynioti V, Lagogianni E, Kalogeromitros D, Katsambas A. Tacrolimus ointment 0.1% in the treatment of allergic contact eyelid dermatitis. J Eur Acad Dermatol Venereol. 2009;23(4):382-387.