What is the treatment for a pediatric patient with a rash around the eyes and mouth?

Pediatric Rash Around Eyes and Mouth: Treatment Approach

For a pediatric patient with a rash around the eyes and mouth, immediately determine if this represents herpes simplex virus (HSV) infection, varicella-zoster virus (VZV) infection, or another etiology, as viral causes require urgent antiviral therapy within 24 hours to prevent devastating ocular complications. 1

Immediate Assessment for Red Flag Features

Urgent ophthalmology referral (within 24 hours) is mandatory if any of the following are present: 2, 1

• Visual changes or decreased vision
• Moderate-to-severe eye pain
• Photophobia
• Corneal involvement (fluorescein staining)
• Severe purulent discharge
• History of HSV eye disease

Viral Etiologies Requiring Immediate Treatment

Herpes Simplex Virus (Herpetic Gingivostomatitis with Periocular Involvement)

Start oral acyclovir 400 mg five times daily for 7-10 days immediately if HSV is suspected, as peak viral titers occur in the first 24 hours. 1 Alternative regimens include valacyclovir 500 mg two to three times daily or famciclovir 250 mg twice daily. 1

Mandatory topical ocular antiviral therapy must be added: 1

• Ganciclovir 0.15% gel three to five times daily (preferred due to less ocular surface toxicity) 2, 1
• OR trifluridine 1% solution five to eight times daily (causes epithelial toxicity if used beyond 2 weeks) 2, 1

Critical: Never use topical corticosteroids alone or without concurrent antiviral therapy, as corticosteroids potentiate HSV infection and can cause devastating progression. 2, 1

Immediate ophthalmology consultation is required, with follow-up within 1 week including visual acuity measurement and slit-lamp biomicroscopy. 2, 1

Varicella-Zoster Virus (Chickenpox with Eyelid Involvement)

For VZV involving the eyelid, start oral valacyclovir 1000 mg three times daily for 7 days (or acyclovir 800 mg five times daily for 7 days) immediately, as periocular involvement carries risk of serious ocular complications including conjunctival scarring, keratitis, corneal scarring, uveitis, and retinitis. 3 For children under 8 years, dose acyclovir at 20 mg/kg (maximum 800 mg) five times daily. 2

Apply topical antibiotics to eyelid vesicles to prevent secondary bacterial infection, which can lead to necrosis, scarring, and cicatricial ectropion. 2, 3

Immediate ophthalmology referral is mandatory for any signs of ocular involvement beyond simple eyelid vesicles. 3

Non-Viral Etiologies

Perioral Dermatitis

If the rash consists of flesh-colored or erythematous papules, micronodules, and rare pustules in a perioral and periorbital distribution without vesicles or systemic symptoms, consider perioral dermatitis. 4

Treatment approach: 4

• Discontinue any topical fluorinated corticosteroids immediately
• Start topical metronidazole alone OR in combination with:
  • Oral erythromycin (for children under 8 years)
  • Oral tetracycline or doxycycline (for children 8 years and older) 2
• A low-potency topical steroid may be used briefly to suppress inflammation and wean off strong steroids

Atopic Dermatitis with Periocular Involvement

For mild periocular dermatitis without red flag features, start preservative-free ocular lubricants (hyaluronate or hydroxypropyl-guar drops) 2-4 times daily. 5

For moderate cases, add olopatadine antihistamine eye drops twice daily. 5

For persistent or severe cases, tacrolimus 0.1% ointment once daily to external eyelids and lid margins demonstrates an 89% response rate and is the most effective topical treatment. 5

Impetigo

If honey-crusted lesions are present around the mouth and eyes, consider impetigo caused by Staphylococcus aureus or Streptococcus pyogenes. 6, 7

Treatment: 7

• Topical mupirocin for localized lesions
• Oral antibiotics for extensive involvement:
  • Cephalexin or cefdinir (first choice due to favorable spectrum and dosing)
  • Dicloxacillin or amoxicillin-clavulanate (alternatives)
  • Consider community MRSA coverage if not responding

Critical Management Principles

Eye Care During Acute Phase

Daily ophthalmological review is necessary during acute illness for any periocular rash with ocular involvement. 2

Apply ocular lubricant (nonpreserved hyaluronate or carmellose eye drops) every 2 hours through acute illness. 2

Ocular hygiene must be carried out daily with gentle saline irrigation to remove mucous or debris. 2

Mouth Care During Acute Phase

Daily oral review is necessary during acute illness. 2

Apply white soft paraffin ointment to the lips every 2 hours through acute illness. 2

Clean the mouth daily with warm saline mouthwashes or an oral sponge. 2

Use an anti-inflammatory oral rinse or spray containing benzydamine hydrochloride every 2-4 hours, particularly before eating. 2

Consider a potent topical corticosteroid mouthwash (betamethasone sodium phosphate) four times daily for severe mouth involvement. 2

Common Pitfalls to Avoid

• Never delay antiviral therapy for viral cultures or confirmatory testing if HSV or VZV is suspected clinically 1
• Never use topical antivirals alone as monotherapy for HSV—oral antivirals are essential 1
• Never use topical corticosteroids for suspected viral infections without concurrent antiviral therapy 2, 1
• Do not delay ophthalmology referral beyond 4 weeks if symptoms persist despite appropriate first-line therapy 5

Follow-Up Protocol

Review at 2-4 weeks to assess treatment response and escalate therapy if no improvement or worsening symptoms. 5

For viral infections, follow-up within 1 week of treatment initiation must include interval history, visual acuity measurement, and slit-lamp biomicroscopy. 2, 1

If symptoms persist beyond 2-3 weeks or worsen at any time, immediate re-evaluation is mandatory. 1, 3