Demographic and clinical characteristics of patients with eyelid eczema attended at a referral service from 2004 to 2018

mong the etiologies of eyelid eczema, allergic contact deratitis (ACD) is the most frequent one. The allergens, in hese cases, can be present in products applied directly o the eyelids (e.g.: eye drops), to other areas, such as he scalp (e.g.: shampoos) and nails (e.g.: nail polish), or ven dispersed in the environment (e.g.: perfumes acting s aeroallergens).1--5 There are few Brazilian studies on the subject and thus, he importance of the present study, which aimed to deterine demographic and clinical characteristics of patients ith eyelid eczema undergoing patch testing at a reference ervice between 2004 and 2018, their etiologies and allerens. Data from medical records of patients with eyelid czema who were submitted to patch testing during he study period were retrospectively assessed. These ests followed the application and reading methodology ecommended by the International Contact Dermatitis esearch Group. According to the anamnesis, the allerens used in the tests were: Brazilian standard battery 30 substances/FDA-Allergenic, RJ, Brazil), cosmetics (10 ubstances/FDA-Allergenic, RJ, Brazil), Latin American batery (24 substances/Chemotechnique Diagnostics, Malmo, weden), also called regional or extended standard, hair attery (15 substances/IPI ASAC, SP, Brazil) and, when posible, individual allergens and the patient’s own products. he Finn Chamber (Smart Practice, USA) or Allergo Chamber Neoflex, São Paulo, Brazil) were used in the tests. The study included 228 patients, 204 (89.5%) of which ere females and 24 (10.5%) males. The higher proportion f women is consistent with the literature and justified by he higher use of cosmetic products that cause palpebral CD in the female population.6,7 The mean age of patients was 45 years. Regarding ethicity, 114 (50%) were white, 42 black (18%), 68 were brown 30%), and 4 were yellow (1.75%). Regarding atopy, 91

Allergic contact dermatitis caused by Kathon CG found in cosmetics.
(39.9%) had a personal history and 66 (28.9%) had a family history of atopy. The time lenght of the dermatosis evolution had a median value of 12 months.
Regarding the clinical aspects, 148 (64.5%) had eczema lesions in other regions of the body in addition to the eyelids, such as other areas of the face in 118 (51.8%), arms in 82 (36%), hands in 52 (22.8%), legs in 47 (20.6%), trunk in 43 (18.9%) and scalp in 24 (10.5%). The higher proportion of involvement in other areas of the face and upper limbs can be explained by the greater use of cosmetic products in these regions ( Figs. 1 and 2).
Of the 228 cases, 183 (80.3%) had at least one positive patch test. However, after establishing the relevance, this number decreased to 147 patients (64.4%), of which 94 (41.2%) had just one relevant positive result, 31 (13.6%) had two, and 22 (9 .6%) had three or more. In a similar French study; 56.4% had at least one relevant positive test result. 7 The use of the Brazilian standard and cosmetics batteries in patch tests made it possible to diagnose the vast majority of ACD cases (84.3%). However, it is noteworthy that the use of other batteries was adopted in the service only from 2014 onwards. Among the patients with a final diagnosis of ACD, the main etiologies were nail polish in 53 (36%), topical medications in 40 (27.2%), unspecified cosmetics in 36 (24.5%), hair dyes in 20 (13.6%), metals in 23 (15.6%), rubber in ten (6.8%) and shampoos in six (4%). The relevant allergens are shown in Table 1.
Literature studies show that cosmetics are the main cause of eyelid ACD, most often due to fragrances and preservatives, with the main allergens being: sodium gold thiosulfate, perfume mix, balsam of Peru, and nickel sulfate. 6,8 Thus, the present sample is compatible with the literature, with cosmetics also being the main etiology.
The toluene-sulfonamide-formaldehyde resin present in nail polish was the most common relevant allergen among those analyzed. It is a substance responsible for giving resistance and shine to nail polish. As the habit of using nail polish is common in our country, this allergen causes sensitization in a significant portion of the population, with values higher than those found in other countries. 6,9 Another common allergen among ACD cases was paraphenylenediamine, found in most permanent hair dyes. Interestingly, only seven of the 21 patients with positive tests relevant to this allergen had concomitant lesions on the scalp, showing that patients with ACD caused by hair dye may present with eczema on the eyelids only, other areas of the face, and the cervical region. 10 The preservatives Kathon CG and formaldehyde as well as fragrances are also observed on sensitizers present in cosmetic products in cases of eyelid ACD. 6,8,9 The allergen with the highest exclude positivity in the analyzed tests was nickel sulfate, although its frequency was lower among the relevant positive tests (15.6% of eyelid ACD cases). They can be a cause of eyelid ACD due to their presence in metal products (e.g., eyelash curlers) and as makeup contaminants. The accidental transfer of nickel on contact from the hands to the eyelids is also common. 8,9 Regarding topical medications, the main allergens were neomycin and promethazine. These can cause ACD by direct contact (use of eye drops or accidental contact after application to another area) or by distant sensitization. 6 Seven of the cases were of occupational origin: three manicurists (caused by toluene-sulfonamide-formaldehyde resin from nail polishes and nickel sulfate from metallic instruments); one masseuse (caused by Kathon present in the massage lotion); one mason (caused by cement potassium bichromate and carba/thiuram-mix of rubber gloves); one installer of aluminum frames and one-floor installer (in both cases caused by the epoxy resin of the glues and grout).
The main limitations of the study were the use of different complementary batteries and two types of chambers in the tests, which configure the non-homogeneity of technical instruments in the evaluation.
Cases related to the use of cosmetics prevailed in the study, with emphasis on nail polish, although other causes LETTER -RESEARCH were observed. Thus, when treating patients with eyelid eczema, the investigation with patch tests is essential.

Financial support
None declared.

Authors' contributions
Mariana de Figueiredo Silva Hafner: Design and planning of the study; drafting and editing of the manuscript; collection, analysis, and interpretation of data; effective participation in research orientation; intellectual participation in the propaedeutic and/or therapeutic conduct of the studied cases; critical review of the literature; critical review of the manuscript; approval of the final version of the manuscript.
Victoria Cerqueira Elia: Drafting and editing of the manuscript; collection, analysis, and interpretation of data; approval of the final version of the manuscript.
Rosana Lazzarini: Drafting and editing of the manuscript; collection, analysis, and interpretation of data; effective participation in research orientation; intellectual participation in the propaedeutic and/or therapeutic conduct of the studied cases; critical review of the literature; critical review of the manuscript; approval of the final version of the manuscript.
Ida Alzira Gomes Duarte: Design and planning of the study; drafting and editing of the manuscript; collection, analysis, and interpretation of data; effective participation in research orientation; intellectual participation in the propaedeutic and/or therapeutic conduct of the studied cases; critical review of the literature; critical review of the manuscript; approval of the final version of the manuscript. and distinct skin disease characterized by multiple pruriginous skin lesions, 2 and its pathophysiological mechanisms remain unknown; however, the involvement of an atopic predisposition has been suggested. 2 CPG in AD is highly intractable to traditional treatments. Herein, we present the cases of four elderly patients with AD complicated by CPG in whom traditional treatments had failed previously and describe their successful treatment with dupilumab within the last 2 years.
The clinical characteristics of the four patients are shown in Table 1. The AD in the four patients was complicated by CPG (Fig. 1A). None of the patients had a history of childhood AD, but the onset of AD was noted in old age. As previous tra-