What can I do to prevent recurring periorbital (around the eye) cellulitis and abscesses, given my history of repeated hospitalizations for this condition?

Managing Recurrent Periorbital Cellulitis and Abscesses

You need immediate surgical drainage of any current abscess, followed by a systematic search for underlying causes—including chronic sinusitis, environmental allergies, or foreign material—combined with a 5-day decolonization regimen and prophylactic antibiotics if you continue having 3-4 episodes per year despite addressing predisposing factors. 1, 2

Immediate Management of Active Infection

Surgical Intervention

• Incision and drainage is mandatory for any abscess, as this is the primary treatment—antibiotics play only a subsidiary role 1
• Early drainage and culture of recurrent abscesses is essential to identify the causative pathogen 1
• After drainage, treat with a 5-10 day course of antibiotics active against the isolated organism 1

Antibiotic Selection for Active Infection

• For periorbital cellulitis with systemic signs (fever, rapid progression, or SIRS), use vancomycin or another MRSA-active agent plus coverage for streptococci 1
• If purulent drainage is present, MRSA coverage is indicated—use vancomycin 15-20 mg/kg IV every 8-12 hours or clindamycin 600 mg IV every 8 hours 1, 3
• Blood cultures should be obtained in patients with systemic features 1, 4

Identifying and Treating Underlying Causes

This is the critical step that hospitals often miss—you must systematically investigate why this keeps recurring. 2

Search for Local Anatomic Causes

• A recurrent abscess at the same site demands evaluation for local factors such as foreign material, pilonidal cyst, or hidradenitis suppurativa 1
• Obtain CT imaging of the sinuses to evaluate for chronic sinusitis, which is a common underlying cause of recurrent periorbital cellulitis 2, 4
• In one case series, 14 of 16 CT scans showed significant sinus disease requiring surgical management 4
• If chronic sinusitis resistant to medical management is identified, surgical intervention (functional endoscopic sinus surgery) may be curative 2

Evaluate for Non-Infectious Triggers

• Environmental allergies can cause recurrent periorbital inflammation that becomes secondarily infected 2
• Allergic contact dermatitis from cosmetics or other topical products should be considered 2
• Vesicular lesions suggest herpetic infection—treat with antiviral therapy if confirmed 2
• In rare cases, factitious disorder (self-injection of irritants) may be the cause 2

Assess for Immunologic Defects

• If recurrent abscesses began in early childhood, evaluate for neutrophil disorders 1
• Adult-onset recurrent abscesses do not typically require neutrophil function testing 1

Prevention Strategy: Decolonization Protocol

For recurrent S. aureus infections, implement a 5-day decolonization regimen: 1

• Intranasal mupirocin twice daily for 5 days 1
• Daily chlorhexidine body washes 1
• Daily decontamination of personal items including towels, sheets, and clothing 1

This regimen should be repeated periodically (some protocols suggest monthly for 5 days) if recurrences continue 1

Long-Term Prophylactic Antibiotics

If you continue having 3-4 episodes per year despite treating predisposing factors and completing decolonization, prophylactic antibiotics are indicated: 1

Prophylaxis Regimens

• Oral penicillin V or erythromycin twice daily for 4-52 weeks is the standard approach 1
• Intramuscular benzathine penicillin every 2-4 weeks is an alternative 1
• Continue prophylaxis as long as predisposing factors persist 1
• Annual recurrence rates of cellulitis are 8-20% in patients with previous episodes, justifying this approach 1

Evidence for Prophylaxis

• Two randomized trials demonstrated substantial reduction in recurrences with twice-daily oral penicillin or erythromycin 1
• Prophylaxis is most effective when combined with aggressive management of underlying risk factors 5

Critical Predisposing Factors to Address

Local Risk Factors

• Treat any tinea pedis or toe web abnormalities, as eradicating colonization reduces recurrence risk 1
• Manage venous insufficiency and lymphedema with compression therapy once acute infection resolves 1
• Address obesity, eczema, and chronic edema 1

Systemic Factors

• Control diabetes if present 5
• Avoid tobacco use 1
• Address any history of trauma or surgery to the affected area 1

When to Escalate Care

Seek immediate surgical consultation if you develop: 3

• Severe pain out of proportion to examination findings (suggests necrotizing fasciitis) 3
• Rapid progression despite antibiotics 3
• Visual changes, proptosis, or ophthalmoplegia (suggests orbital involvement) 4, 6
• Systemic toxicity with hypotension or altered mental status 1, 3

Why Standard Hospital Care May Be Failing You

The fundamental problem is that most emergency departments and hospitals focus only on treating the acute infection with antibiotics and drainage, without investigating the underlying cause or implementing prevention strategies. 2, 5 This approach guarantees recurrence. You need a provider who will:

1. Obtain sinus imaging to rule out chronic sinusitis 2, 4
2. Culture the abscess to guide targeted therapy 1
3. Implement decolonization protocols 1
4. Consider prophylactic antibiotics if episodes continue 1
5. Refer to ENT if chronic sinusitis is identified 2

Consider seeking care at a different facility with infectious disease specialists who can provide comprehensive evaluation rather than repeated acute-only treatment. 5 Recurrent cellulitis requires specialized, multidisciplinary management to break the cycle. 5