Recurrent Bilateral Eyelid Dermatitis in a Young Adult Male

Case at a Glance

A 32-year-old male with a 10-year history of seasonal allergic conjunctivitis presented with recurrent episodes of bilateral eyelid swelling, erythema, and desquamation with discharge, showing seasonal variation and partial response to topical corticosteroids.

Patient's Story

The patient reported a decade-long history of seasonal eye allergies managed with topical antihistamines (alcaftadine and olopatadine). Approximately one year prior, he developed acute bilateral eyelid swelling and erythema during summer months. The condition progressed to include desquamation and discharge from the eyelid margins, with minimal ocular surface involvement. Symptoms completely resolved in November but briefly recurred during a trip to Florida in February before resolving again. The current episode began one month ago with similar presentation.

Initial Assessment

Physical examination revealed bilateral eyelid erythema, swelling, and flaking with discharge from the lid margins. Visual acuity and intraocular examination were unremarkable. The patient's long-standing allergic conjunctivitis was well-controlled with topical antihistamines. Initial differential diagnosis included allergic contact dermatitis, atopic dermatitis, seborrheic dermatitis, and infectious etiologies.

The Diagnostic Journey

Initial ophthalmologic evaluation resulted in treatment with tobramycin-dexamethasone ointment, which provided symptom resolution but required continuous use for maintenance. Topical calcineurin inhibitor (pimecrolimus) caused significant ocular irritation without therapeutic benefit. Allergologic workup included standard environmental allergen skin prick testing, which was negative. Intradermal testing revealed mild reactions to mold and dust mites only. Two separate allergists provided conflicting recommendations regarding patch testing, with one dismissing its utility and the other suggesting it was a dermatologic issue.

Final Diagnosis

Recurrent eyelid dermatitis, likely allergic contact dermatitis with seasonal triggers, pending patch testing for definitive allergen identification.

Treatment Plan

Discontinuation of unsupervised topical corticosteroid use due to potential complications. Referral to dermatology for comprehensive evaluation and patch testing to identify contact allergens. Ophthalmologic re-evaluation to rule out concurrent ocular pathology before resuming topical medications. Consideration of alternative topical anti-inflammatory agents such as ruxolitinib cream if calcineurin inhibitors continue to cause irritation.

Outcome and Follow-up

Patient scheduled for coordinated care involving dermatology and ophthalmology. Emphasis placed on proper diagnostic workup including patch testing before long-term treatment decisions. Patient counseled on the importance of avoiding unsupervised topical corticosteroid use around the eyes and the need for systematic allergen identification to prevent future episodes.