Treatment for Mild Periorbital Cellulitis
For mild periorbital cellulitis, a 5-7 day course of oral antibiotics such as cephalexin 500 mg 3-4 times daily is the recommended first-line treatment. 1
Distinguishing Periorbital from Orbital Cellulitis
It's crucial to correctly identify periorbital cellulitis (infection anterior to the orbital septum) versus orbital cellulitis (infection posterior to the septum):
- Periorbital cellulitis: Limited to eyelids in the preseptal region, more common and less severe 2
- Orbital cellulitis: Involves contents of the orbit, potentially threatens vision and life 3, 2
Signs suggesting orbital involvement requiring immediate escalation:
- Decreased visual acuity
- Pain with eye movement
- Proptosis
- Ophthalmoplegia (limited eye movement)
- Fever ≥38°C with systemic symptoms 1
Antibiotic Treatment Algorithm
First-Line Treatment:
- Beta-lactam antibiotics 1:
- Cephalexin 500 mg 3-4 times daily for 5-6 days
- Amoxicillin-clavulanate 875/125 mg twice daily for 5-6 days
For Beta-lactam Allergies:
- Clindamycin 300-450 mg orally three times daily for 5-6 days 1
- Doxycycline 100 mg twice daily for 5-6 days (avoid in children under 8) 1
For MRSA Suspicion:
- TMP-SMX 1-2 DS tablets twice daily plus metronidazole 500 mg three times daily 1
Supportive Measures
- Elevate the affected area to promote gravity drainage of edema 1
- Warm compresses may help with comfort and circulation
- Address predisposing conditions (eczema, sinusitis) to prevent recurrence 1
Monitoring and Follow-up
- Improvement should be seen within 48-72 hours
- If no improvement or worsening symptoms, reassess for:
- Orbital involvement
- Inadequate antibiotic coverage
- Abscess formation requiring drainage
Common Pitfalls
- Failure to distinguish between periorbital and orbital cellulitis - orbital cellulitis requires more aggressive treatment and possible surgical intervention 2
- Inadequate treatment duration - extend therapy if clinical response is inadequate 1
- Failure to address underlying causes - particularly sinusitis, which is a common source 4, 5
- Overuse of broad-spectrum antibiotics - reserve vancomycin and newer agents for severe infections or confirmed MRSA 1
Special Populations
- Children: Cephalexin preferred over doxycycline for those under 8 years 1
- Immunocompromised patients: May need more aggressive treatment and broader coverage 1
If symptoms worsen or fail to improve within 48-72 hours, immediate reassessment is necessary to rule out orbital involvement, which may require intravenous antibiotics and possible surgical intervention 2, 5.