In a 78‑year‑old man with known dry‑eye disease and seborrheic dermatitis who now presents with facial itching and a sticky eye, what is the most likely diagnosis and what is the first‑line management?

Diagnosis: Seborrheic Blepharitis with Meibomian Gland Dysfunction

This 78-year-old man with seborrheic dermatitis presenting with facial itching and sticky eye most likely has seborrheic blepharitis with meibomian gland dysfunction (MGD), and first-line management should include topical ketoconazole 2% cream to the face, daily warm compresses with lid hygiene, and preservative-free lipid-containing artificial tears. 1, 2, 3

Clinical Reasoning

The constellation of pre-existing seborrheic dermatitis, facial itching, and sticky eye strongly suggests ocular involvement of his dermatologic condition. 95% of patients with seborrheic blepharitis have seborrheic dermatitis elsewhere on the body, confirming this is a systemic condition affecting multiple sebaceous-rich sites simultaneously. 2 Additionally, patients with seborrheic dermatitis have significantly elevated rates of dry eye disease (18-40%) and meibomian gland dysfunction (34.5%). 2

The "sticky eye" presentation is characteristic of MGD, where thickened meibomian secretions accumulate on the lid margins and lashes, particularly noticeable upon awakening. 1

First-Line Treatment Protocol

Step 1: Treat the Underlying Seborrheic Dermatitis

• Apply ketoconazole 2% cream to affected facial areas twice daily for four weeks or until clinical clearing. 3, 4 This is FDA-approved for seborrheic dermatitis and addresses the Malassezia yeast colonization that drives the inflammatory response. 3, 4
• Antifungal treatment is the mainstay of therapy because the condition results from an inflammatory response to Malassezia yeast. 4

Step 2: Implement Daily Eyelid Hygiene

• Apply warm compresses to closed eyelids for 5-10 minutes once or twice daily to soften crusted material and liquefy thickened meibomian secretions. 1, 5
• Immediately follow with gentle lid massage to express meibomian gland secretions from the glands. 1, 5
• Cleanse eyelid margins using diluted baby shampoo or commercial eyelid cleaners on a cotton pad to remove crusting and reduce bacterial load. 1, 5
• This regimen must be performed regularly (daily or several times weekly) because symptoms often recur when treatment is discontinued. 1

Step 3: Ocular Lubrication

• Start preservative-free artificial tears containing lipid supplements at least 4 times daily, increasing to hourly as needed based on symptoms. 1, 2, 5, 6
• Lipid-containing formulations are specifically indicated when MGD is present, as they address the evaporative component of dry eye. 1, 5
• Apply lubricating ointment at bedtime for overnight protection. 5

Important Considerations for Elderly Patients

In patients over 65 years with pruritus and dry eye, moisturizers with high lipid content are preferred, and sedating antihistamines should be avoided due to fall risk and anticholinergic effects. 1 This patient should receive emollients for his facial itching rather than oral antihistamines. 1

When to Escalate Treatment

If symptoms persist after 2-4 weeks of first-line therapy, escalate to:

• Topical antibiotic ointment (bacitracin or erythromycin) applied to lid margins once daily or at bedtime for bacterial colonization. 1, 5
• Topical cyclosporine 0.05% or lifitegrast for anti-inflammatory therapy if dry eye symptoms remain significant. 2, 6
• Short-term topical corticosteroids (hydrocortisone 1% for periocular skin due to thin, sensitive tissue in this area). 5
• Oral doxycycline for moderate to severe blepharitis not responding to topical therapy, providing both antimicrobial and anti-inflammatory effects. 1, 5

Critical Pitfalls to Avoid

• Do not use prolonged topical corticosteroids on the eyelids without monitoring, as this can lead to glaucoma, cataracts, and skin atrophy. 1, 5
• Advise patients with glaucoma not to place aggressive pressure on lids during massage, as this may increase intraocular pressure. 1
• Ensure the patient has adequate manual dexterity to perform lid hygiene safely, as improper technique can damage the corneal epithelium, especially in elderly patients. 1
• Screen for systemic associations including rosacea and Parkinson's disease, which are common in this population and may require additional management. 2