What is the recommended treatment for a periorbital (around the eye) skin infection?

Treatment of Periorbital Skin Infection

For periorbital skin infections (preseptal cellulitis), initiate systemic oral antibiotics with coverage for Staphylococcus aureus and Streptococcus species; use cephalexin 500mg twice daily or dicloxacillin 500mg four times daily for 7-10 days, with close monitoring for progression to orbital involvement. 1, 2

Initial Assessment and Risk Stratification

Immediately distinguish between preseptal (periorbital) and orbital cellulitis, as orbital involvement is a medical emergency requiring IV antibiotics and hospitalization. 2, 3

Key clinical features indicating preseptal cellulitis only (safe for outpatient oral therapy):

• Eyelid edema and erythema WITHOUT proptosis 2
• Normal extraocular movements 3
• No vision changes 3
• No pain with eye movement 4

Red flags requiring immediate hospitalization and IV antibiotics:

• Any proptosis, ophthalmoplegia, or vision changes indicate orbital involvement 2, 4
• Age under 1 year (higher risk of Haemophilus influenzae and rapid progression) 2
• Severe systemic toxicity or sepsis 3
• Failure to improve within 24-48 hours on oral therapy 3

Antibiotic Selection for Uncomplicated Preseptal Cellulitis

First-line oral therapy (choose one):

• Cephalexin 500mg twice daily - preferred for convenience and compliance, equally effective as four-times-daily regimens 1
• Dicloxacillin 500mg four times daily - alternative with anti-staphylococcal coverage 1

Rationale: Staphylococcus aureus is the most common pathogen (cultured in approximately 30% of cases), followed by Haemophilus influenzae in younger children. 2 Most staphylococcal strains are penicillin-resistant but sensitive to cephalexin and dicloxacillin. 1

For patients with MRSA risk factors (prior MRSA infection, recent hospitalization, injection drug use):

• Add trimethoprim-sulfamethoxazole or doxycycline for MRSA coverage 4
• Consider obtaining wound cultures if there is purulent drainage 2

Common Predisposing Factors to Address

Identify and treat underlying sources:

• Skin trauma or local infection (most common in adults) 2
• Upper respiratory tract infection 2
• Sinusitis (especially in children and when orbital involvement develops) 2, 4
• Dermatitis or other skin breakdown allowing bacterial entry 4

Monitoring and Follow-Up

Expect clinical improvement within 24-48 hours:

• Reduced eyelid edema and erythema 1
• Decreased pain and tenderness 1
• Resolution of systemic symptoms 3

If no improvement by 48 hours:

• Hospitalize for IV antibiotics (ampicillin plus methicillin or vancomycin) 2
• Obtain imaging (CT scan) to rule out orbital extension or abscess formation 4
• Consider surgical drainage if abscess is present (required in approximately 23% of hospitalized cases) 2

Critical Pitfalls to Avoid

Do not treat periorbital cellulitis with topical antibiotics alone - systemic therapy is mandatory as this is a deep soft tissue infection, not a superficial skin infection. 3

Do not delay hospitalization in high-risk patients - periorbital cellulitis can rapidly progress to orbital cellulitis with vision-threatening and life-threatening complications including meningitis, cavernous sinus thrombosis, and brain abscess. 3, 4

Recognize that aggressive bacterial skin infections are becoming more common and early recognition with prompt systemic antibiotic therapy prevents serious complications. 4