Do recurring styes (hordeolum) in children indicate an underlying condition?

Recurring Styes in Children: Clinical Significance

Recurring styes in children warrant evaluation for underlying ocular rosacea, as children with a history of styes have an increased risk of developing adult rosacea and may already have subtle signs of pediatric ocular rosacea that can lead to vision-threatening complications if unrecognized. 1

Key Underlying Conditions to Consider

Ocular Rosacea (Most Important Association)

• Children with recurrent styes have a significantly increased risk of developing adult rosacea (5.5% vs 1.5% in controls without childhood styes, P = 0.01). 2
• Rosacea is frequently overlooked in children because they may present with recurrent chalazia, styes, chronic keratoconjunctivitis, or meibomian gland dysfunction (MGD) while having only subtle facial signs of rosacea. 1
• Facial rosacea is less frequent in children than ocular manifestations, and associated atopy is common in pediatric cases. 1
• Children with ocular rosacea can develop serious complications including corneal involvement, asymmetry of ocular disease, corneal melting, and perforation—complications that occur more frequently in children than adults. 1

Blepharokeratoconjunctivitis (BKC)

• Recurrent styes are a diagnostic criterion for BKC in children, defined as "a syndrome usually associated with anterior or posterior lid margin blepharitis, accompanied by episodes of conjunctivitis, and a keratopathy." 3
• BKC is more severe in Asian and Middle Eastern children, with statistically higher risk of subepithelial punctate keratitis (p = 0.008), corneal vascularization (p <0.001), and marginal corneal ulcerations (p = 0.003). 3
• Without treatment, severe staphylococcal blepharitis may lead to eyelash loss, eyelid scarring with trichiasis, and corneal scarring and neovascularization. 1, 4

Chronic Blepharitis

• Blepharitis is a chronic condition with periods of exacerbation and remission that can begin in childhood, though onset usually occurs in middle-aged adults. 1
• The incidence of ulceration and perforation complications is greater in children compared to adults with blepharitis. 1

Clinical Evaluation Algorithm

What to Look For on Examination:

• Eyelid margin findings: telangiectasia, meibomian gland orifice narrowing/pouting, cylindrical dandruff at eyelash base (suggests Demodex), blood-tinged debris 1
• Facial skin examination: erythema, telangiectasia, papules, pustules, prominent sebaceous glands (may be subtle in children) 1, 4
• Corneal examination: punctate epithelial keratitis, phlyctenules, marginal keratitis, corneal neovascularization, ulceration 1, 3
• Asymmetry of ocular involvement (suggests ocular rosacea in children) 1

Important Pitfalls to Avoid:

• Do not dismiss recurrent styes as benign in children—they may represent early ocular rosacea before facial manifestations appear. 1
• Rosacea is difficult to diagnose in darker skin tones because telangiectasia and facial flushing are not visible; emphasize hyperpigmentation and symptoms of burning/stinging. 4
• In children, pediculosis palpebrarum (pubic lice) causing blepharitis may indicate sexual abuse and requires appropriate evaluation. 1

Management Considerations

Treatment Approach:

• Most children with BKC show reduction in symptoms and signs with treatment, and progression of disease after age 8 is rare. 3
• Treatment regimen incorporates lid hygiene, topical and/or systemic antibiotics, and topical corticosteroids as needed. 3
• Therapy is effective and loss of sight can be prevented in most cases when appropriately treated. 3

Medication-Related Causes to Consider:

• Isotretinoin (for severe acne) is associated with increased S. aureus colonization, blepharitis, and tear dysfunction; discontinuation leads to improvement. 1
• Dupilumab (for atopic dermatitis) is associated with conjunctivitis, keratitis, and blepharitis in 32-55% of patients. 1

Evidence Quality Note

There is no high-quality evidence for specific treatments of acute hordeolum—Cochrane reviews found no randomized controlled trials meeting inclusion criteria for non-surgical interventions. 5, 6 However, the association between childhood styes and underlying conditions, particularly ocular rosacea, is well-established in ophthalmology guidelines. 1