Not Just Pink Eye: Allergic Contact Dermatitis to Alcaftadine 0.25% Ophthalmic Solution

Periorbital dermatitis is frequently due to allergic contact dermatitis (ACD) and patients describe symptoms of swelling, itch, and redness on the eyelids and surrounding skin [1]. Common causative allergens include metals, preservatives, fragrances, and acrylates, whereas common sources include cosmetics and other personal care products, jewellery and nail products [1-3]. Additionally, allergens in topical medications, mainly eye drops and antibiotics, have been recognised as important precipitants of periorbital ACD [1-5]. Patient 1 (64-year-old female) with a history of Sjögren's syndrome with keratoconjunctivitis sicca and corneal scar of the left eye presented with a 4-year history of intermittent periorbital redness and swelling (Figure 1a). Patient 2 (50-year-old female) with a history of Sjögren's syndrome presented with a 4-month history of recurrent eyelid dermatitis described as itchy, scaly and red. Patient 3 (38-year-old female) with a history of bilateral retinal lattice degeneration and prior retinal surgeries presented with a 6-month history of recurrent periorbital dermatitis associated with itching, swelling and conjunctival injection (Figure 1c). All patients were using alcaftadine 0.25% solution (Lastacaft) drops and other eye care products for several months to years (Table 1). Patch testing was performed using a standard technique with Finn Chambers (SmartPractice, Phoenix) on Scanpor tape (Norgesplaster Alpharma AS Vennesla, Norway) and included the North American Contact Dermatitis Group (NACDG) screening series, an expanded cosmetic series, and custom patches to the patients' eye drops and relevant eye care products. The skin was gently scratched prior to the application of eyedrops as previously described [7]. All three patients tested positive (+, Figure 1b,d) to Lastacaft (ingredients: benzalkonium chloride, edetate disodium, monobasic sodium phosphate, purified water, sodium chloride, sodium hydroxide, hydrochloric acid) and negative to benzalkonium chloride and other eye products at days 4 and 5 (Table 1). Of the two patients with clinical follow-up, both showed improvement with discontinuation of Lastacaft drops. Standard Supplemental Cosmetic Plants Corticosteroids Standard Supplemental Cosmetic Standard Supplemental Cosmetic Lastacaft (alcaftadine 0.25%), antihistamine drops Lotemax (loteprednol 0.5%), corticosteroid gel Systane, lubricant drops Blink, lubricant drops Boston, rewetting drops Fluorometholone, cortiscosteroid drops Prednisolone, corticosteroid drops Lastacaft (alcaftadine 0.25%), antihistamine drops Restasis (cyclosporine 0.05%) drops Lotemax (loteprednol 0.5%), corticosteroid gel Refresh, lubricant drops OCuSOFT, eyelid cleanser Lastacaft (alcaftadine 0.25%), antihistamine drops Biotrue, moisturising drops Potassium dichromate 0.25% (pet): + (UR) Benzisothiazolinone 0.1% (pet): + (UR) Fragrance mix I 8.0% (pet): + (CR) Lauryl glucoside 3.0% (pet): + (CR) decyl glucoside 5.0% (pet): + (CR) Alcaftadine, the active ingredient in Lastacaft, is primarily a H1 histamine receptor antagonist and mast cell stabiliser. It is available in the United States as an over-the-counter medication and is commonly used in the treatment of itching associated with allergic conjunctivitis. Prior to this report, only one case of ACD to alcaftadine 0.25% solution had been described [8]. Ketotifen and olapatadine are other antihistamines used as active ingredients in eyedrop solutions and have also been reported to cause ACD [9, 10]. Antihistamine eye drops are used to treat allergic conjunctivitis and ACD to these agents can present with similar symptoms, such as itching, swelling, and redness, delaying timely recognition and treatment. This report highlights the importance of considering patients' ophthalmic products as causes of periorbital dermatitis. Custom patch testing to these products can help identify novel allergens, such as alcaftadine, that are not included in a standard series and would otherwise be missed as important allergens. Mayra Betancourt Ponce: conceptualization, writing – original draft, investigation, writing – review and editing. Margo Reeder: writing – review and editing, investigation, methodology, validation, supervision, conceptualization. All patients provided written informed consent for the use of their photographs in this manuscript. Consent was obtained in accordance with institutional guidelines and ethical standards for publication. The authors declare no conflicts of interest.