Intended for healthcare professionals

Practice Practice Pointer

Periocular rash

BMJ 2018; 363 doi: https://doi.org/10.1136/bmj.k5098 (Published 21 December 2018) Cite this as: BMJ 2018;363:k5098
cropped thumbnail of infographic

Infographic available

Periocular rash

  1. Christina George, dermatology registrar1,
  2. Sarah Walsh, consultant dermatologist2
  1. 1Royal London Hospital, London, UK
  2. 2King’s College Hospital, London, UK
  3. Correspondence to: C George cgeorge2@nhs.net

What you need to know

  • Take a focused history of the rash and consider examining the whole skin surface, not just the periocular site, to narrow down the differential diagnosis

  • Expect improvement in a periocular rash around 7-10 days into a trial of treatment (aside for suspected rosacea)

  • If the rash does not improve, check how much and how frequently treatments have been used so far, and review the diagnosis

  • For topical treatment, creams may be more cosmetically acceptable to patients than ointments, but ointments penetrate the skin more effectively

  • Consider referral for those who have not responded to treatment, where there is diagnostic uncertainty, the person is systemically unwell, or for patch testing

Skin problems around the eyes can be challenging to diagnose because the differential is wide. They can also be difficult to manage because the periorbital skin is sensitive, and there are a multitude of treatment options, with little specific guidance on their use. This practice pointer outlines the common causes of a periocular rash in an adult, and offers an approach to help diagnosis and management.

How to approach the periocular rash

Start by taking a focused history of the rash, including the time course and symptoms. A diagnostic approach and key clinical features of each diagnosis are summarised in the infographic. Consider examining the whole skin surface, not just the periocular site—often the distribution of the rash on the face and other body sites is key to making an accurate diagnosis.1 Box 1 provides further pointers to consider when examining the patient. Factors in the history and examination can help differentiate which type of pathology is the predominant problem. For example, inflammation (endogenous such as atopic eczema, or exogenous such as irritant dermatitis), oedema, dyspigmentation, and systemic diseases can all cause periocular rashes.

Box 1

Clinical examination of periocular rash—key features

Morphology

  • Scaly rash—Consider eczematous conditions such as atopic eczema, contact allergic dermatitis, …

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