Recurrent Asymmetric Periorbital Swelling During CORONA Pandemic

Sir,

A 36-year-old married school teacher presented with intermittent otherwise asymptomatic swelling of eyes and periorbital region for the last 15 days. The swelling used to subside with residual subtle pigmentation within 2 days and then reappear on either or both periorbital regions. On examination [Figure 1], periorbital edema with underlying erythema was seen on the left side involving both upper and lower eyelids. Diffuse hyperpigmentation was noticed in the right periorbital region. She had no history suggestive of contact dermatitis, atopic diathesis, photosensitivity, or any other systemic illness. She did not use any ophthalmic medications; facial, nail, hair, or eye cosmetics; and/or sanitizer on the face. During her job in a secondary school, she had been using an alcohol-based hand sanitizer (ABHS) frequently for hand hygiene for the last 3 months continuously, without any similar complaints. She denied touching her eyes in between and did not change the brand or formulation of the sanitizer. Complaints started after winters started. A presumptive diagnosis of contact dermatitis was made and she was asked to apply emollients liberally and repeatedly along with 1% hydrocortisone cream at bedtime. She was also counseled to become extra vigilant regarding any possible contact allergen or irritant. She revisited after 2 weeks happy to announce that she had nailed the culprit. Due to extreme cold prevailing in north India, she had started covering her face, as shown in Figure 2, for the last 2 months. She was using an alcohol-based sanitizer spray on her shawl in the pretext of protection from Covid illness. The same shawl was causing irritation on eyelids. She stopped spraying her shawl and was symptom-free for 10 days now. Assessment of this case on the Naranjo Adverse Drug Reaction probability scale revealed this contact dermatitis to be a probable adverse effect secondary to ABHS.

Figure 1.

Edema and erythema in periorbital regions

Figure 2.

Face covered with cloth that touched the eyes intermittently

The recent COVID pandemic has resulted in a worldwide hygiene and cleanliness drive to the level of obsession. CDC recommends using ABHS having >60% ethanol or >70% isopropranolol for hand hygiene to prevent transmission of COVID disease.[1] CDC has also provided instructions for laundering clothing and linen.[2] For hand hygiene, fragrance-free ABHS with moisturizers has the least cutaneous sensitizing and irritancy potential when compared to soaps and detergents. Disinfectants should not be used on skin. Dermal contact with ethanol causes irritation and allergic condition of skin and eyes.[3] Irritant contact dermatitis to hand hygiene is the most common occupational dermatoses among health care workers and personnel working in the food industry. It occurs as dry, erythematous, scaly, and fissured skin over hands that has a burning sensation and feels rough.[4] The most likely cause for reactions to ethanol applied to the skin is oxidative metabolism, which may be caused by hypersensitivity to either alcohol itself, aldehyde metabolites, or some other additive of the topically applied products.[5]

This case is being reported for the hitherto unreported contact dermatitis of eyes secondary to sanitizer in this era of COVID pandemic. Besides, a vigilant patient is an important clog in solving the riddle of contact dermatitis.

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The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.