Course of treatment
Clinically, with good patient compliance, most cases of pediatric blepharitis resolve in one to two weeks, when the initial findings are mild to moderate.
Differences may exist between different pediatric populations. It has been reported in Asia that pediatric patients have a more severe presentation and that clinical resolution requires a longer period of management.10
In cases of recalcitrant blepharitis, or when the patient presents with atypical findings that do not fit the profile of blepharitis, clinicians should reconsider their working diagnosis and determine if a less common cause is the culprit.11
Fortunately, a good history, observation, and anterior segment evaluation will often be enough to make a diagnosis of blepharitis. Tests and procedures used in ocular surface disease management in adults, such as Schirmer tests, tear osmolarity, and meibomian gland expression are not likely to be successful when the patient is a child.
Whenever possible, use of sodium fluorescein (and possibly other vital dyes) should be attempted to assist in evaluating potential lid changes and meibomian gland and tear quality and corneal integrity. Based on the overall severity of clinical findings, an assessment of severity can be made and management adjusted accordingly
Most patients will respond to a tier approach: lid hygiene measures should be initiated first, with topical medications added next, and when necessary, prescribing systemic medications
Lid hygiene is the core treatment in blepharitis. It is important to stress that blepharitis is a chronic condition and that treatment must be maintained even after symptoms improve to avoid a relapse.
Many times the directions for lid hygiene will incorporate a three-step approach with heat and massage targeting meibomian gland complications, lid cleaning targeting debris removal from the eyelid skin and lashes, and artificial tears following the other management for generalized removal of debris from the cul-de-sac. Each step can be enhanced or modified based on the specific findings of a patient and the severity of disease.
Heat is particularly important for posterior blepharitis because it softens meibomian gland secretions and breaks up dried discharge. Lid cleaning is essential for anterior blepharitis because it reduces the overall bacterial population and the associated exotoxins. Due to the fact that clinically, blepharitis may have contributions from multiple causes, a lid hygiene routine usually incorporates both heat and cleansing.12
Milder cases of blepharitis may resolve with lid hygiene alone. A good start is to apply a clean washcloth soaked in warm water on top of closed eyelids for five to 10 minutes, one to two times daily. Implementing the practice during bath time is often easiest. For children who are preschool age or older, the parent might challenge the child to keep the warm face cloth on his eyes with music used as a timer. The “game” is presented as, “Don’t take off the washcloth until the end of the song (or songs).”
After heat, a gentle massage over the closed eyes is ideal and may incorporate diluted baby (no-tear) shampoo on the lid margins.8 In addition, numerous commercial wipes are available, including Systane Lid Wipes and OCuSOFT Lid Scrubs—including a commercially available Baby Eyelid and Eyelash Cleanser. Although no-tear baby shampoo is a less expensive option, some families may prefer the convenience of the pre-moistened wipes, particularly for traveling and diaper bags, or if someone else in the family is already using lid wipes.
Artificial tears may also be added to the management regimen to help to remove allergens and address associated dry eye linked to a MGD component.
Related: Understanding and defining MGD
Seborrheic dermatitis may occur in children. In infants, it appears as scaly, greasy patches on the scalp known as cradle cap. In older children, seborrheic dermatitis is associated with dandruff that may appear to be crusty or itchy.
Seborrheic blepharitis may present as an isolated, acute presentation, but it is more likely chronic in nature. Chronic blepharitis that is associated with seborrheic dermatitis is best treated by tackling the underlying cause. An over-the-counter dandruff shampoo will reduce the general debris and oiliness associated with seborrhea.
Options for children include California Baby Tea Tree & Lavender Shampoo & Body Wash, Puriya Dandruff shampoo, Sulfur 8 Kids Anti Dandruff Medicated Shampoo, and Head & Shoulders Instant Oil Control Shampoo.