Eyebrow lifting using multidirectional absorbable thread

Background

Thread lifting is a common procedure in minimally invasive esthetic techniques and can also be used to raise the drooping soft tissue of the forehead by vertically inserting threads into the forehead.

Aims

This study aimed to examine the effect of forehead thread lifting on enhancing upper eyelid opening.

Methods

Fifteen patients were included in this study, all of whom underwent eyebrow thread lifting with MINT LIFT® UP. Photographs of the patients were taken before, immediately after, and 1 and 12 weeks after surgery. Changes in the position of the eyebrows and eyelids were measured. The paired t-test was used to determine the statistical significance of differences.

Results

At 1 week after surgery, the eyebrows were at a lower level compared with before surgery, and no significant changes in eye-opening were observed. However, at 12 weeks after surgery, the eyebrows and upper eyelids were both significantly elevated when compared to the preoperative state.

Conclusions

Eyebrow lifting can be performed using multidirectional thread lifting.     

Ultra-minimal pinhole blepharoplasty: A minimally invasive technique for the correction of eyelid bags

Objective

The aim of the study was to investigate the efficacy and complications of ultra-minimal pinhole blepharoplasty in the treatment of eyelid bags.

Methods

This retrospective study included patients with eyelid bags treated using a minimally invasive blepharoplasty technique between May 2018 and June 2021. The postoperative course and complications and patient satisfaction were analyzed.

Results

A total of 460 patients (136 males and 324 females) were included with a mean age of 42.12 ± 9.76 years. The mean operative time was 24.3 min. After the operation, the patients had no infection, numbness, or lower eyelid varus, valgus, or withdrawal. Nine patients developed transient binocular diplopia, which disappeared 0.5–1 h after surgery. Two patients developed chemosis, which disappeared after therapy. Six months after the operation, 440 (95.65%) patients were satisfied with improvement in their fat bulge. A total of 434 (94.78%) patients were satisfied with improvement in their tear groove.

Conclusion

Ultra-minimal pinhole blepharoplasty is a safe, effective, and minimally invasive treatment for eyelid bags.     

Efficacy of topical latanoprost in the treatment of eyelid vitiligo: A randomized,double‐blind clinical trial study

Numerous studies have demonstrated that the pigmentation of iris and around the eyelid is a common side effect of latanoprost, a prostaglandin F2alpha analogue used in the treatment of glaucoma. Hence, the authors decided to study the effectiveness of topical latanoprost on vitiligo patches around the eyelid. In this randomized, double‐blind, clinical trial study, 31 patients with vitiligo vulgaris and focal vitiligo involving the eyelids were evaluated. Patients were randomly divided into two groups. First group received topical latanoprost gel twice daily for 12 weeks, whereas the second group received placebo with the same protocol. To evaluate severity of the disease the VIDA rating system was used. Serial photos of the patches were taken to compare and evaluate the repigmentation percentage of the patches. The patients in both groups had almost similar VIDA score (p > .05). First group showed improved pigmentation, whereas participants in the second group did not show any improvement in the pigmentation. The group treated with latanoprost showed significant reduction in the symptoms of the disease, whereas those treated with placebo did not show any alteration (p > .05). No significant complications were observed in either groups. Latanoprost proved effective in treating vitiligo disease involving eyelids.     

The severity of wrinkling at the forehead is related to the degree of ptosis of the upper eyelid

Background: Most studies on wrinkle formation have focused on changes in the dermal condition that promote the fixation of transiently formed wrinkles. Little is known about the age‐dependent changes in transient wrinkle formation in response to altered facial expression or the mechanism leading to fixed wrinkle formation. Objective: To clarify the mechanism of wrinkle formation at the forehead, we investigated the factors that influence the severity of transient wrinkling and the relationship of transient with fixed wrinkles, using a newly established method to evaluate transient wrinkle formation. Methods: Transient wrinkles were generated by requesting subjects to gaze in an upward direction. Foreheads of the subjects with or without an upward gaze at a fixed angle were photographed and the severity of wrinkles at the forehead was graded from 0 to 5 in 50 healthy Japanese female volunteers in their 20s, 40s, or 60s. Skin elasticity was measured using a Cutometer^®. Frontalis muscle activity and ptosis of the upper eyelid were estimated by measuring movement of the eyebrow during upward gazing and the position of the upper eyelid of the open eye, respectively. Results: Wrinkles formed transiently at the forehead by upward gazing were highly reproducible in each subject. Their severity increased with aging and was highly correlated to that of fixed wrinkles (R=0.81, P<0.001). Therefore, this method appears to be suitable for studying the mechanism of transient wrinkle formation and the relationship between transient and fixed wrinkles at the forehead. The severity of transient wrinkles was correlated with elevation of the eyebrow during upward gazing (R=0.69, P<0.001), but not with dermal elasticity. This suggests that transient wrinkles are induced by increased frontalis muscle activity during upward gazing. Frontalis muscle activation was negatively correlated with upper eyelid position (R=−0.37, P<0.05), which descended with aging, meaning ptosis of the upper eyelid, and negatively correlated with the severity of transient wrinkles induced by upward gazing (R=−0.43, P<0.05). Furthermore, the upper eyelid position was also negatively correlated with the severity of fixed wrinkles (R=−0.44, P<0.05). Conclusion: These results suggest that ptosis of the upper eyelid is associated with increased activation of the frontalis muscle during upward gazing and increased severity of transient and fixed wrinkling at the forehead.     

Periorbital Hyperpigmentation: A Study of its Prevalence,Common Causative Factors and its Association with Personal Habits and Other Disorders

Background:

Periorbital hyperpigmentation (POH) is one of the most commonly encountered conditions in routine dermatology practice. There are only few published studies about its prevalence, classification, and pathogenesis but none showing its association with habits, and other medical conditions in Indian patients.

Aims:

To determine prevalence and type of POH, common causative factors, and its association with personal habits and other disorders within various age and sex groups.

Materials and Methods:

Two hundred patients attending the dermatology OPD were included in study and were subjected to detailed history, careful clinical and Wood''s lamp examination, eyelid stretch test and laboratory investigations. Clinical photographs of all patients were taken.

Results:

POH was most prevalent in 16-25 years age group (47.50%) and in females (81%) of which majority were housewives (45.50%). Commonest form of POH was constitutional (51.50%) followed by post inflammatory (22.50%). Lower eyelids were involved in 72.50%. Grade 2 POH was seen in 58%. Wood''s lamp examination showed POH to be dermal in 60.50%. Faulty habits were observed viz. lack of adequate sleep (40%), frequent cosmetic use (36.50%), frequent eye rubbing (32.50%), and lack of correction for errors of refraction like myopia in 12% patients. Strong association of POH with stress (71%), atopy (33%) and family history (63%) was noted.

Conclusions:

Periorbital hyperpigmentation is a multi-factorial entity. It is absolutely essential to classify the type of POH and determine underlying causative factors in order to direct appropriate measures for better and successful outcome in future.     

Squamous cell carcinoma of the eyelid arising from palpebral conjunctiva

We reported a 58-year-old Japanese man with squamous cell carcinoma (SCC) of the left upper eyelid arising from the palpebral conjunctiva. The tumor had been incised by a former doctor under the diagnosis of chalazion. Histopathological examination of the relapsed tumor revealed atypical squamous cells invading towards the eyelid skin from the epithelium of palpebral conjunctiva. We performed a total resection of the tumor and reconstructed the upper eyelid by the technique of Mustarde's switch flap. During 10 months of follow-up, neither local recurrence nor metastasis has been detected and the reconstructed eyelids showed good course in function and in appearance. SCC of the palpebral conjunctiva is quite rare, however, it often resembles chronic conjunctivitis or chalazion. It is important to consider the possibility of SCC in addition to sebaceous carcinoma when we see a patient with an eyelid lesion, even one which looks like a benign condition such as chronic conjunctivitis or chalazion.     

Risk factors associated with relapse of eyelid basal cell carcinoma: results from a retrospective study of 142 patients

Background

Of skin cancers, 9% arise at the periocular level, constituting a significant threat due to the proximity to intracranial structures, such as the eyes, nerve endings and proximal tissues. Tumour recurrence can be frequent and represents a primary clinical challenge for the surgeon.

Objectives

To present a retrospective study on the treatment of eyelid tumours at a tertiary care centre in Italy over an eight-year period and, in particular, to underline the risk factors associated with tumour relapse.

Materials & methods

Among a cohort of 205 patients, a retrospective study was conducted on 142 basal cell carcinoma (BCC) patients with eyelid tumours treated with surgical excision. Relapse-free survival was assessed using univariate Kaplan-Meier and multivariate Cox regression analysis.

Results

Over an eight-year study period, we detected 23 cases of BCC recurrence, with tumour localization associating with tumour relapse, representing an independent risk factor. The extent of the area of excision was significantly associated with relapse, but not margin positivity whichwas associated with reduced relapse-free survival.

Conclusion

To minimize relapse of basal cell carcinoma during patient management, relevant factors to consider before and after tumour excision include tumour localization, margin invasion, and extension of the excision, but not the surgical technique used.

     

Tacrolimus ointment in the treatment of eyelid dermatitis

The safety and efficacy of tacrolimus ointment 0.1% (Protopic) in the treatment of atopic dermatitis of the eyelids were assessed in an open-label clinical trial of 21 patients with moderate to severe eyelid dermatitis. Of those 21 patients, 20 received study drug and were followed. Patients applied tacrolimus ointment 0.1% twice daily for 8 weeks and were followed for 2 additional weeks after the last day of treatment. Complete eye examinations were conducted throughout the study. Efficacy was assessed through the investigator's evaluation of the patients' individual signs and symptoms of eyelid dermatitis and the physician global assessment (PGA) of eyelid clinical response. Improvement in the investigator's evaluation of the signs and symptoms of eyelid dermatitis was observed during the study. A total of 80% of patients (16/20) experienced marked improvement or better in PGA at 8 weeks. Adverse events were limited to local burning and itching after the first few applications of study medication. Of the 20 patients, 12 reported burning (60%), and 5 reported itching (25%). There was no statistically significant increase in intraocular pressure (IOP) during the study compared with baseline. In addition, none of the patients developed cataracts or glaucoma during the study. In summary, tacrolimus ointment 0.1% may be a safe and effective treatment option for patients with moderate to severe eyelid dermatitis.     

Sebaceous carcinoma of the eyelid treated with Mohs micrographic surgery

BACKGROUND: Sebaceous carcinoma is an aggressive neoplasm that commonly arises from the meibomian glands of the eyelids and other sebaceous glands of the ocular adnexa. Historic data indicate a nearly 30% local recurrence rate with standard surgical excision. Excision by means of Mohs micrographic surgery may be more efficacious. However, reports documenting the effectiveness of this technique for the treatment of eyelid sebaceous carcinoma have been limited to a few cases. OBJECTIVE: We report our experience in the treatment of ocular sebaceous carcinoma with the Mohs fresh tissue technique. METHODS: Eighteen patients with a diagnosis of sebaceous carcinoma of the eyelid who underwent resection by means of the Mohs fresh tissue technique during the years 1988-1998 were reviewed. RESULTS: Sixteen of the 18 patients were free of disease after an average follow-up of 37 months (11.1% recurrence rate). One patient who experienced local recurrence also had metastatic disease of the parotid lymph nodes (5.6% metastatic rate). The recurrence and metastasis were noted 9 months after excision. The other patient experienced a local recurrence 19 months postoperatively. Both patients exhibited pagetoid spread and involvement of both the upper and lower eyelid at the time of Mohs excision. CONCLUSION: Mohs surgery offers excellent results when used as the primary treatment modality for sebaceous carcinoma of the eyelid. When compared with historic series of standard surgical excision, Mohs micrographic surgery has a significantly lower recurrence rate and metastatic rate.     

High incidence of demodicidosis in eyelid basal cell carcinomas

BACKGROUND: Although UV radiation is the major cause of basal cell carcinoma (BCC), local factors, such as chronic trauma, irritation, or inflammation, may also have some role in its etiopathogenesis. The pilosebaceous follicle mites, Demodex folliculorum and D. brevis, inhabit most commonly and densely certain facial skin areas, including the nose and periorbital regions, where BCC also develops most frequently. AIM: To investigate, in a retrospective histopathologic study, whether a possible etiopathogenetic relationship exists between demodicidosis and eyelid BCCs. METHODS: We examined 32 eyelid BCC specimens that contained at least five eyelashes or five hair follicles with respect to the presence and density of Demodex mites. As controls, we evaluated 34 matched specimens consisting of benign eyelid skin lesions. RESULTS: Twenty-one of 32 BCC cases (65.6%) and eight of 34 control cases (23.33%) had demodicidosis. Mean mite counts were 1.31 +/- 1.57 and 0.47 +/- 0.99 in BCC cases and controls, respectively. The differences were significant for both prevalence (P < 0.001) and density (P = 0.0052). Although there was a significant positive correlation between increasing mite number and patient age in the control group (r = 0.47, P < 0.05), no significant correlation was found between these two factors in BCC cases (r = -0.102, P > 0.05). CONCLUSIONS: Demodicidosis may be one of the triggering factors of carcinogenesis in eyelid BCCs in otherwise predisposed people due to its traumatic/irritating effect or chronic inflammation.     

Eyelid skin tightening: a novel ‘Niche’ for fractional CO2 rejuvenation

Background The periorbital area is a barometer of chronologic and environmental age for which patients usually seek rejuvenation; fractional CO₂ laser plays a key role among the variety of available dermatologic treatments. Objectives The purpose of this study is to evaluate the efficacy and safety of Fractional CO₂ laser in eyelid tightening and periorbital wrinkles. Methods Forty‐five patients received a range of 2–3 treatments in the upper, lower eyelids and periorbital area with a fractional laser device. Photographs were taken before and after each treatment and 2 weeks, 4 weeks, 3 months, 6 months and 12 months after the final treatment. The results were judged by three dermatologists who had not taken part in the treatments. Results One year after the last laser session, all patients showed global improvements in eyelid skin tightening: five patients (11.1%) achieved excellent improvement, 11 patients (24.5%) marked improvement, 15 patients (33.3%) moderate improvement and 14 subjects (31.1%) slight improvement. At the 1‐year follow‐up, the percentage of subjects with a lift in their eyebrows and consequently a widened palpebral fissure was 82.2 (37 patients), whereas 17.8% (eight patients) showed no eyebrow elevation. Conclusions Fractional CO₂ laser treatments allow dermatologists to achieve notable improvements in eyelid skin tightening, and eyebrow elevation safely and without significant side‐effects.     

Sufficient mesh polyhedral intralesional injection for treatment of keloids

Background

The recurrence of keloids after intralesional injections is significant, and a review of the literature shows an inconsistent range of success rates. In this study, the modified medical proportion and intralesional injection method were intended to enhance the treatment effect.

Methods

Twenty patients completed the study. Regional block anesthesia (lidocaine, ropivacaine) was performed. Triamcinolone acetonide (40 mg/mL), 5-fluorouracil (25 mg/mL), and ropivacaine (7.5 mg/mL) were configured in a ratio of 2:1:4 and applied on the lesion by reticular injection (horizontal fan-shaped stratified and vertical shaking pressurized injection). The minimum volume of injection per square centimeter was approximately 3.5 mL. The outcome indicators were the Vancouver Scar Scale (VSS), Visual Analogue Scale (VAS), treatment frequency.

Results

The patients had an 82% ± 7% average reduction in VSS scores and 89% ± 13% and 93% ± 10% reductions in VAS scores of pain and pruritus, respectively, after an average of 2.5 ± 0.7 injections administered within 1 year.

Conclusion

The sufficient mesh polyhedral intralesional injection can achieve excellent results for the treatment of keloid scars.     

Infraorbital mass long after dermal filler injection: A report of two cases

Background

Hyaluronic acid fillers have been increasingly used throughout the world in the management of aging skin in the periocular region and other areas.

Objective

To evaluate very late-term orbital mass formation secondary to Hyaluronic acid filler injection into the inferior eyelid.

Methods

We report two cases that presented with a subcutaneous palpable mass localized at the right medial lower infraorbital area. Following clinical and radiological examination, surgical excision was required for the differential diagnosis of tumor.

Results

After pathologic examination and the finding of a foreign-body granulomatous reaction, both patients recalled that hyaluronic acid filler had once been injected into their lower eyelids approximately 10 years prior. This is consistent with the fact that dermal-filler-related granuloma formation may occur even years later in the differential diagnosis of mass lesions.

Conclusion

It is suggested that patients be informed about the possible but rare mass effect in the infraorbital region. Clinicians should also attend to delayed hypersensitivity reactions, since patients may not recall details due to the length of time since injection.     

Periorbital (eyelid) dermatides

Physicians in various specialties—and dermatologists in particular—frequently encounter various forms of inflammation of the eyelids and of the anterior surface of the eye. Distinguishing the cause of itchy, painful, red, edematous eyelids is often difficult. Because the uppermost layer of the eyelids is part of the skin that wraps the entire body, almost every skin disease in the textbook can affect the periorbital area as well. In this contribution, we focused on the most common such disorders that require special consideration, as a result of their special appearance, their challenging diagnosis, or the nature of their treatment. We reviewed the key features of several common dermatides that affect the eyelids, such as atopic dermatitis, seborrheic dermatitis, allergic contact dermatitis, airborne contact dermatitis, rosacea, psoriasis, and others. We focused on the special clinical features, causes, and treatments specific to the delicate skin of the eyelids. Because structures of the eye itself (ie, the conjunctiva, the cornea, the lens, and the retina) may be involved in some of the discussed periorbital skin diseases, we found it useful to add a brief summary of the eyelid complications of those diseases. We then briefly reviewed some acute sight-threatening and even life-threatening infections of the eyelids, although dermatologists are not likely to be the primary care physicians responsible for treating them.     

Evaluation of dark circles of the lower eyelid: comparison between reflectance meters and image processing and involvement of dermal thickness in appearance

Background/aims: Dark circles of the lower eyelid (DCLE) represent a well-known beauty problem. The pathogenesis of DCLE is obscure, although stasis and hyperpigmentation of the eyelids have been considered to be involved. One reason for the small number of studies on DCLE may be the difficulty in measuring such soft and curved skin as the eyelids using bulky reflectance meters. The purpose of this study was to quantitatively analyze DCLE using various bioengineering methods.
Methods: The lower eyelid and cheek areas of 14 subjects with DCLE and 28 without DCLE were examined using two kinds of reflectance meters and image analysis to measure erythema index (EI), melanin index (MI), and oxygenation index (OX). Ultrasound echo images were also recorded to evaluate the thickness and echo density of the dermis. An in vitro model using collagen gel and hemoglobin solution was also examined as a phantom of eyelid skin.
Results: When contact-type reflectance meters were used, no significant differences in EI, MI, and OX were found between groups with and without DCLE. However, mean values of both MI and EI at eyelids were significantly higher in subjects with DCLE on image analysis, paralleling the results of inspection. Mean dermal thickness was significantly smaller in subjects with DCLE.
Conclusion: Evaluation of EI and MI by image processing methods seems suitable for quantitative evaluation of DCLE, since inadequate contact of the measuring head with the skin is avoided. Whether stasis or hyperpigmentation is more responsible for DCLE remains uncertain. Dermal thickness of eyelid skin may be involved in the appearance of DCLE.     

Unilateral eyelid angioedema with congestion of the right bulbar conjunctiva due to loxoprofen sodium

Angioedema is a variant of urticaria that causes deep dermal and subcutaneous swelling. It frequently is a unilateral reaction and usually lasts for several hours but may persist for several days. We report 2 cases of angioedema that involved the right upper and lower eyelids and was associated with congestion of the right bulbar conjunctiva; the symptoms started approximately 1 to 2 hours after taking loxoprofen sodium. All of the symptoms subsided after oral corticosteroid therapy. In both cases, an oral challenge test with 60 mg of loxoprofen sodium (contained in a tablet) caused swelling of the right upper eyelid within several hours, followed by swelling of the right bulbar conjunctiva. We believe the drug reaction in both patients is angioedema.     

Epigenetic inactivation of the E-cadherin gene in eyelid sebaceous gland carcinoma

Background E‐cadherin and β‐catenin are crucial components of the cell–cell adhesion complex. Their loss has often been associated with tumour metastasis and poor clinical outcome. Both loss of E‐cadherin at the cell membrane and a stabilizing mutation in CTNNB1 (β‐catenin gene) have been associated with ovarian, colorectal, hepatocellular and nonmelanoma skin cancer, such as squamous and basal cell carcinomas. Absence of E‐cadherin may be caused by promoter hypermethylation of the E‐cadherin gene (CDH1). Objectives To determine the role of E‐cadherin promoter hypermethylation and CTNNB1 gene mutation in the aggressive behaviour of sebaceous gland carcinoma of the eyelid. Methods Thirty‐six cases of sebaceous gland carcinoma were subjected to E‐cadherin methylation‐specific polymerase chain reaction and mutational analysis for the CTNNB1 gene. E‐cadherin and β‐catenin staining was evaluated by immunohistochemistry. Results were correlated with the clinicopathological features of sebaceous gland carcinoma. Results Methylation of the E‐cadherin promoter region was detected in 72% of eyelid sebaceous gland carcinoma cases and loss of E‐cadherin immunostaining in 83%. E‐cadherin promoter hypermethylation showed a significant association with the loss of membranous E‐cadherin (P = 0·038) and it was of borderline significance with reduced disease‐free survival (P = 0·05). It was also found to be associated with advanced age (73%), tumour size ≥ 2 cm (77%), orbital invasion (83%), lymph node metastasis (60%), tumour recurrence (60%) and poor histological differentiation (90%). DNA sequencing revealed no stabilizing β‐catenin gene mutation in sebaceous gland carcinoma. Loss of membranous β‐catenin was observed in 61% cases, which associated significantly with both E‐cadherin promoter methylation (P = 0·0262) and loss of E‐cadherin membranous localization (P = 0·0015). Conclusion Epigenetic inactivation of the E‐cadherin gene causes loss of membrane‐bound E‐cadherin and could contribute to the reduced disease‐free survival in eyelid sebaceous gland carcinoma. Mutations in the β‐catenin gene do not seem to be involved in the pathogenesis of eyelid sebaceous gland carcinoma.     

Intraepithelial sebaceous carcinoma of the eyelid misdiagnosed as Bowen's disease

BACKGROUND: Sebaceous carcinoma (SC) is well known for its ability to masquerade clinically and histologically as a variety of periocular conditions resulting in a delayed diagnosis. We present a series of periocular SC cases and discuss the difficulties in histopathological diagnosis when this tumor presents with a Bowenoid pattern of intraepithelial spread. METHODS: A retrospective case study of all patients with SC of the eyelid treated in our Hospital, from 1997 to 2004, was conducted. RESULTS: Eight patients were identified (four females and four males). Seven cases involved the upper eyelid. Initial clinical diagnoses included blepharitis (three cases), blepharoconjunctivitis (one case), cicatrizing conjunctivitis (one case), and lid lesions (two cases). Histopathologically, 87.5% of cases were misdiagnosed as Bowen's disease (BD) on the initial biopsy. Six of these cases showed no invasive disease on the initial biopsy and were eventually found to be invasive SC on subsequent excisions. In one case, the tumor was wholly in situ. Delay in diagnosis ranged from 0 to 56 months. CONCLUSIONS: SC should always be considered in the histological differential diagnosis of any eyelid lesion which resembles BD, particularly if the upper eyelid is involved or if multivacuolated cytoplasmic clear cell changes are seen.     

Primary systemic amyloidosis: a unique case complaining of diffuse eyelid swelling and conjunctival involvement.

A 52-year-old Japanese woman with the chief complaint of marked swelling of her upper eyelids and a mass over the bulbar conjunctiva is reported. She previously noticed frequent purpura after minimal trauma, which was resolved shortly after taking some ascorbic acid. Laboratory data showed Ig-G kappa type M-protein in the serum and kappa type Bence-Jones protein in the urine by immunoelectrophoresis. Systemic examination showed mild hepatosplenomegaly, 1st degree of AV block, and a mild increase in plasma cells in the bone marrow biopsy. Histologically, the whole dermis of the eyelid skin and conjunctiva was replaced by a large quantity of amorphous, eosinophilic substances, which were diffusely positive with Direct Fast Scarlet 4BS. Immunohistochemical staining was positive for anti-amyloid P component antibody. Typical amyloid fibrils were proved by electron microscopy. She was finally diagnosed as primary systemic amyloidosis with diffuse swollen eyelids and conjunctival mass, symptoms which in primary systemic amyloidosis are very rare.     

The Eyelid Sign: A Clue to Bed Bug Bites

In pediatric patients, determining the culprit insect in arthropod assaults can be challenging. The patient’s history may be vague, the causative insect may not be readily associated with the bites, and the clinical appearance of bites can be variable. Six pediatric patients from the Penn State Milton S. Hershey Medical Center dermatology offices with bed bug bites were identified. All had bites involving the face, trunk, and extremities. Five patients demonstrated papules on one upper eyelid associated with erythema and edema. One patient had papules on both upper eyelids. When an arthropod assault is suspected, the “eyelid sign,” i.e., bites involving the upper eyelid associated with erythema and edema, may point to bed bugs.