Could an 11.5-year-old with a pinpoint rash under the right eye and a history of eyelid swelling be diagnosed with blepharitis?

This is unlikely to be blepharitis and requires urgent evaluation for viral infection

An 11.5-year-old with a pinpoint rash under the right eye combined with transient eyelid swelling should be evaluated for viral conjunctivitis, particularly herpes simplex virus (HSV), rather than blepharitis. The combination of a vesicular/pinpoint rash and acute eyelid swelling in a child is a red flag for HSV infection, which can cause serious complications if not recognized early.

Why This Is Not Typical Blepharitis

Blepharitis presents with chronic symptoms that are fundamentally different from this acute presentation:

• Blepharitis is chronic and bilateral with symptoms that worsen in the morning, including burning, irritation, and crusting at the lash bases 1, 2
• The hallmark findings are at the eyelid margin itself: collarettes at lash bases, meibomian gland dysfunction, lid margin hyperemia, and scaling 1, 3
• Blepharitis does not cause pinpoint rashes under the eye or acute transient eyelid swelling as the primary presentation 1, 4

The Concerning Diagnosis: Herpes Simplex Virus

The clinical picture strongly suggests HSV infection:

• HSV characteristically presents with vesicular rash or ulceration of the eyelids in children, often unilateral 1
• Eyelid swelling is a prominent feature and can even resemble orbital cellulitis on examination 1
• HSV is more common in pediatric patients and can be bilateral in this age group 1
• The "pinpoint rash" likely represents early vesicular lesions that are pathognomonic for HSV 1

Critical Complications to Prevent

This child needs immediate ophthalmologic evaluation because HSV can cause vision-threatening complications:

• Epithelial keratitis with dendritic ulcers of the cornea 1
• Stromal keratitis leading to corneal scarring, neovascularization, and permanent vision loss 1
• Uveitis, endotheliitis, and even retinitis 1
• Corneal perforation in severe cases 1

Other Viral Causes to Consider

Varicella zoster virus (VZV) should also be on the differential:

• VZV presents with vesicular dermatomal rash and eyelid ulceration, typically with severe pain 1
• Like HSV, it causes unilateral presentation with eyelid swelling and can lead to corneal scarring 1

Adenoviral conjunctivitis is possible but less likely:

• Adenovirus does cause eyelid swelling and can resemble orbital cellulitis 1
• However, it typically presents with watery discharge and follicular conjunctivitis rather than a pinpoint rash 1
• Common in school-aged children with recent exposure to infected individuals 1

Immediate Action Required

Refer urgently to ophthalmology for:

• Slit-lamp examination to evaluate for corneal involvement 1
• Assessment of the rash characteristics (vesicular vs. other) 1
• Fluorescein staining to detect epithelial defects 1
• Consideration of antiviral therapy if HSV is confirmed 1

Common Pitfall to Avoid

Do not dismiss this as simple blepharitis or allergic reaction. The combination of acute unilateral eyelid swelling with a rash in a child warrants immediate evaluation to rule out HSV, which requires prompt antiviral treatment to prevent permanent vision loss 1. While HSV conjunctivitis may resolve in 4-7 days without treatment, complications can develop that cause irreversible damage 1.