Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.
A 27-year-old woman is evaluated for a 1-week history of an intensely pruritic rash on her eyelids. She applied a new brand of eye makeup just prior to the onset of the rash. She immediately discontinued its use and has been applying a moisturizing lotion to both eyelids since then without improvement in her symptoms. She notes no other areas of rash and generally feels well. The patient has no significant medical history and takes no medications.
On physical examination, vital signs are normal. There is erythema, mild edema, and some serous crusting over the upper eyelids bilaterally. No erythema is present on the scalp, face, neck, upper back, shoulders, arms, or fingers. The remainder of the examination is normal.
A 2-week course of which of the following is the most appropriate treatment for this patient?
A: Betamethasone dipropionate
B: Clobetasol propionate
C: Halobetasol propionate
D: Hydrocortisone valerate
MKSAP Answer and Critique
The correct answer is D: Hydrocortisone valerate.
This patient has allergic contact dermatitis of her eyelids, and a low-potency hydrocortisone ointment such as hydrocortisone valerate is the most appropriate treatment. Treatment courses should be of limited duration (2 weeks or less), which can be controlled by dispensing a small size tube (15 g) when treating areas of thin, sensitive skin such as the face or skin folds. There are multiple formulations of hydrocortisone that range in potency (hydrocortisone valerate, fumarate, and more); not all are low potency, and it is important when selecting a topical hydrocortisone to consider the anatomic site to be treated. The eyelids are very thin skin and are exposed to multiple irritants and allergens. Cosmetics, including nail products, shampoo, and fragrances, frequently result in an allergy on the eyelids, even when not directly applied to that location, because of the thin eyelid skin. This patient has mild allergic contact dermatitis; she should avoid the trigger, and topical glucocorticoids will relieve her symptoms.
The other three medications are all very potent topical glucocorticoids. The potencies of topical glucocorticoids in the United States are designated by classification into one of seven groups, with group 7 (1% and 2.5% hydrocortisone) being the least potent and group 1 being the most potent (up to 600 times more potent than the group 7 agents). Higher-potency glucocorticoids can rapidly lead to adverse effects, including lightening of the skin, atrophy, and telangiectasias, when used on areas of thin skin such as the eyelids. In addition, patients are at risk of ocular exposure and eventual cataract formation if chronically exposed. Therefore, treatment of facial lesions is usually limited to low-potency (groups 6 and 7) glucocorticoids.
- Hydrocortisone valerate is a very-low-potency topical glucocorticoid that is safe to use on the eyelids.
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