What is the best course of treatment for a child presenting with multiple pustules on the lower eyelid?

Treatment of Multiple Pustules on the Lower Eyelid in Children

The most likely diagnosis is molluscum contagiosum, and treatment requires physical removal of the lesions through incision and curettage, simple excision, or cryotherapy, combined with topical bland ophthalmic ointment (petrolatum, erythromycin, or bacitracin) applied 2-3 times daily for 10 days to smother remaining viral particles. 1

Diagnostic Approach

The clinical presentation of multiple pustules on the lower eyelid in a child most commonly represents:

• Molluscum contagiosum - dome-shaped, flesh-colored, umbilicated papules that may appear pustular, caused by viral shedding onto the ocular surface 1, 2
• Varicella zoster (chickenpox) - vesicles/pustules on the eyelid that undergo necrosis before healing, often with concurrent systemic illness 1
• Herpes simplex virus blepharoconjunctivitis - vesicular lesions that may appear pustular with associated conjunctivitis 1

Key distinguishing features to examine:

• Umbilication strongly suggests molluscum contagiosum 1, 2
• Systemic vesicular rash indicates varicella 1, 3
• Watery discharge and follicular conjunctivitis suggests viral etiology 1, 4
• Purulent discharge with mattering indicates bacterial superinfection 5

Treatment Algorithm

For Molluscum Contagiosum (Most Likely)

Definitive treatment requires lesion removal: 1

• Incision and curettage (aggressive enough to cause bleeding) 1
• Simple excision 1
• Excision with cautery 1
• Cryotherapy 1

Adjunctive topical therapy: 1

• Apply bland ophthalmic ointment (petrolatum, erythromycin, or bacitracin) 2-3 times daily for 10 days to smother adult lice and nits 1
• Identify and treat nascent lesions to reduce viral load and allow host immune response to eliminate residual virus 1

Important considerations:

• Conjunctivitis may require weeks to resolve after lesion elimination 1
• Large and multiple lesions with minimal conjunctival inflammation may indicate immunocompromised state 1
• Lesions may spontaneously resolve but can persist for months to years 1

For Varicella Zoster (If Systemic Chickenpox Present)

Immediate oral antiviral therapy is mandatory: 3

• Valacyclovir 1000 mg three times daily for 7 days (preferred due to superior bioavailability) 3
• Alternative: Acyclovir 800 mg five times daily for 7 days 1, 3
• Alternative: Famciclovir 500 mg three times daily for 7 days 1, 3

Topical antibiotics to prevent secondary bacterial infection: 1, 3

• Apply topical antibiotic ointment to eyelid vesicles because they undergo necrosis before healing and are vulnerable to bacterial superinfection that can cause severe conjunctival scarring and cicatricial ectropion 1, 3

Critical monitoring: 3

• Immediate ophthalmology referral for conjunctival injection, watery discharge, or corneal symptoms 3
• Watch for pseudodendritic keratitis, stromal keratitis, uveitis, or corneal scarring 1, 3

For Herpes Simplex Virus (If Vesicular with Conjunctivitis)

Combination oral and topical antiviral therapy: 1, 6

• Oral acyclovir 400 mg five times daily for 7-10 days 6
• Alternative: Valacyclovir 500 mg two to three times daily 1, 6
• Alternative: Famciclovir 250 mg twice daily 1, 6

Topical antiviral therapy: 1, 6

• Ganciclovir 0.15% gel 3-5 times daily (preferred due to less ocular surface toxicity) 1, 6
• Alternative: Trifluridine 1% solution 5-8 times daily (but causes epithelial toxicity if used >2 weeks) 1, 6

Critical warning: 1, 6

• Never use topical corticosteroids without concurrent antiviral therapy - they potentiate HSV infection and can cause devastating progression 1, 6

Common Pitfalls to Avoid

• Do not use topical corticosteroids alone for any viral eyelid lesion, as they potentiate viral infections 1, 3, 6
• Do not rely on topical antivirals alone for VZV - they are not helpful as monotherapy 1, 3
• Do not use systemic antibiotics for uncomplicated viral lesions - they provide no benefit and promote resistance 4
• Do not assume molluscum will self-resolve in symptomatic patients - active treatment is indicated 1
• Do not miss immunocompromised state - multiple molluscum lesions with little inflammation suggest underlying immunosuppression 1, 2

Mandatory Ophthalmology Referral Indications

Immediate referral required for: 4, 3

• Visual loss 4, 3
• Moderate to severe pain 4, 3
• Corneal involvement (infiltrate, ulcer, opacity) 4, 3
• Conjunctival injection or watery discharge with eyelid lesions 3
• History of immunocompromise 4, 3
• Neonatal presentation 1, 4

Follow-Up Protocol

• For molluscum: Follow-up not usually necessary unless conjunctivitis persists beyond expected timeframe 1
• For varicella/HSV: Follow-up within 1 week including visual acuity measurement and slit-lamp biomicroscopy 1, 3, 6
• If symptoms persist >2-3 weeks or worsen: Immediate re-evaluation mandatory 3, 6