What is the treatment for a 2-year-old with a chickenpox lesion on the eyelid?

Treatment of Chickenpox Eyelid Lesions in a 2-Year-Old

For a 2-year-old with chickenpox involving the eyelid, apply topical antibiotics to the eyelid vesicles to prevent secondary bacterial infection, and initiate oral acyclovir 20 mg/kg four times daily for 5 days if treatment can begin within 24 hours of rash onset. 1, 2

Antiviral Therapy

• Oral acyclovir is FDA-approved for chickenpox treatment in children aged 2 to less than 18 years at a dose of 20 mg/kg (maximum 800 mg per dose) four times daily for 5 days. 2
• Treatment should ideally be initiated within 24 hours of rash onset for maximum benefit, as this timing significantly reduces lesion count, accelerates healing, and shortens the duration of fever and constitutional symptoms. 3, 4
• If treatment is started between 24-48 hours after rash onset, there is still some clinical benefit, though less pronounced than when initiated on day 1. 4
• Valacyclovir is an alternative with superior bioavailability, but the FDA label specifically states that efficacy and safety have not been established in patients less than 12 years of age for cold sores and less than 2 years for chickenpox. 2 Therefore, acyclovir remains the preferred agent for a 2-year-old. 1, 2

Prevention of Secondary Bacterial Infection

• Apply topical antibiotics directly to eyelid vesicles to prevent secondary bacterial infection, which can lead to necrosis, severe conjunctival scarring, and cicatricial ectropion. 1, 5
• Eyelid vesicles undergo necrosis before healing and are particularly vulnerable to bacterial superinfection. 1, 5
• Common choices include erythromycin or bacitracin ophthalmic ointment applied to the eyelid margins. 1

Critical Monitoring for Ocular Complications

• Immediate ophthalmology referral is mandatory if there are any signs of ocular involvement beyond simple eyelid vesicles, including conjunctival injection, watery discharge, limbal vesicles, or any corneal symptoms. 5, 6
• Monitor specifically for development of conjunctivitis, pseudodendritic keratitis, punctate keratitis, stromal keratitis, uveitis, or corneal scarring. 1, 5
• Varicella can cause serious ocular complications including corneal vascularization, iritis/uveitis, sectoral iris atrophy, and secondary glaucoma. 1

What NOT to Do

• Never use topical corticosteroids for varicella eyelid lesions, as they potentiate viral epithelial infections and can worsen disease. 5, 7
• Topical antivirals alone are not helpful for VZV conjunctivitis and should not be used as monotherapy. 1
• Avoid applying topical antibiotics to the conjunctiva itself (as opposed to eyelid vesicles), as they provide no benefit for viral conjunctivitis and may cause toxicity. 5, 7

Supportive Care

• Use cold compresses to reduce inflammation and provide symptomatic relief. 5, 7
• Artificial tears can provide comfort and help dilute viral particles on the ocular surface. 5, 7
• Oral analgesics (acetaminophen or ibuprofen) may be used for pain management and fever control. 5

Follow-Up Protocol

• Schedule follow-up within 1 week of treatment initiation to assess for resolution of acute symptoms and development of ocular complications. 1, 5, 7
• Follow-up should include visual assessment appropriate for age and examination of the eyelids and ocular surface for signs of complications. 1, 5
• If symptoms persist beyond 2-3 weeks or worsen at any time, re-evaluate immediately with ophthalmology consultation. 5, 7

Important Caveats

• The 5-day course of acyclovir is sufficient, as a 7-day course provides no additional benefit. 4
• Acyclovir treatment reduces the number of lesions (mean 294 vs 347 with placebo), prevents new lesion formation after day 3 in over 95% of patients, and limits fever and constitutional symptoms to 3-4 days. 3
• If the child is immunocompromised, more aggressive treatment with possible intravenous acyclovir (10 mg/kg IV three times daily) may be required. 1