A closer look at allergic contact dermatitis caused by topical ophthalmic medications

Abstract

Background: Allergic contact dermatitis caused by topical ophthalmic medications (OftACD) is frequently difficult to confirm with patch testing and, therefore, it is considered uncommon.Methods: We collected retrospective data from a cohort of 65 patients with suspected OftACD patch tested in our Dermatology Unit (2005)(2006)(2007)(2008)(2009)(2010)(2011)(2012)(2013)(2014)(2015)(2016)(2017)(2018)(2019)(2020)(2021) according to ESCD guidelines, using a series of topical drugs and excipients (Chemotechnique Diagnostics), including betaxolol and timolol 5% pet. kindly supplied by the pharmaceutical industry. Also, frequently used ophthalmic medications as well as patient's own products were also patch tested 'as is' in most patients.Results: Positive patch tests to ophthalmic medications occurred in 44 patients (67.7%) (38F/6M; mean age 63.1 years), with 102 positive reactions. Most positive reactions were associated with active ingredients (n = 56), especially aminoglycoside antibiotics (n = 27), followed by excipients (n = 24) such as sodium metabisulfite (n = 7). There were also positive reactions to topical products tested 'as is' (n = 22), mostly containing beta-blockers, but only five of these reacted to the active ingredient.Discussion: This study reinforces previous findings in OftACD, such as older age of onset, and the importance of antibiotics, contrasting with the progressively lower prevalence of excipients. In addition, it helps raising awareness for the sensitization to beta-blockers, which is probably underestimated. Patch test preparations for the diagnosis of OftACD may require protocol optimization.

Topical eye medications causing allergic contact dermatitis

“…Our results indicate that the clinician should be observant on current dermatitis, as it was the most common persistent symptom (reported by 22%), most often located in the periorbital region. Eyelid symptoms have been reported as the most common location in previous studies, being a part of the periorbital region 1,4 . Interestingly, solitary conjunctivitis was observed in four patients, which has also previously been described 11 …”

“…The frequency of a positive patch test to an eye medication (12.9%) was lower than in two similar European studies (35%–68%) 3,4 . It is uncertain, if this reflects a true difference, or rather an international divergence in the patient selection for patch testing.…”

“…At our department, topical eye medications are tested in large patch test chambers. Recently, light has been shed on the risk of false negative results regarding pure timolol maleate at 5%, why the actual prevalence may be even higher 4 . Of note, no ROAT's were described in the medical records in the 41 patch test positive patients, although it would be more relevant in case of a negative/doubtful test and a history suggesting ACD to an eye medication.…”

“…Allergic contact dermatitis (ACD) in the eye region may be caused by eye medications, and symptoms can be difficult to distinguish from other skin diseases, such as atopic dermatitis (AD), irritant contact dermatitis, psoriasis, rosacea, or seborrheic dermatitis. In patch test populations, the frequency of a positive patch test to an eye medication/ingredient is less than 1%, 1,2 but much higher frequencies (35%–68%) have been demonstrated in populations where a specific suspicion of ACD to an eye medication has been raised 3,4 . Patch test positive patients are usually over 40 years old, and numerous culprits are reported with national differences 1–5 .…”

“…In patch test populations, the frequency of a positive patch test to an eye medication/ingredient is less than 1%, 1,2 but much higher frequencies (35%–68%) have been demonstrated in populations where a specific suspicion of ACD to an eye medication has been raised 3,4 . Patch test positive patients are usually over 40 years old, and numerous culprits are reported with national differences 1–5 . ACD to eye medications is probably underreported due to challenges to identify the culprit allergen 6 …”