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George and Walsh detail an excellent comprehensive review of Periocular Rash in their practice pointer article of 5.1.19. I think however that there is a fundamental omission from their history taking and examination, which is of particular pertinence to General Practice, where the bulk of these conditions will be managed..
They mention that with regard to allergic contact dermatitis “the thin skin of the eyelids may be the first area affected from allergens applied to the face”, but make no mention of allergens applied indirectly via the hands.
The thicker skin of the hands may be protected from overt allergic contact dermatitis, or the reaction may be very minor, but transfer of small amounts of allergen from the hands to the periocular region with its increased vulnerability may provoke such a response.
The history and examination should therefore, in my opinion, include asking about potential allergens which the patient might be getting on their hands, and a good look for signs of hand dermatitis of which the patient may be uncomplaining, but which might provide a pointer towards aetiology.
In practice, over recent years I have found that liquid ‘plunger’ soaps to be particularly culpable.