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Indian Journal of Paediatric Dermatology | Vol 16 | Issue 1 |
January-March 201542
ADDRESS FOR CORRESPONDENCE Dr. Kavitha Dasari,
Skin Assure: Shop No. 8, Golden Hawk Complex, Prenderghast Road,
Secunderabad 500 003, Telangana, India.
Email: [email protected]
(seborrheic blepharitis). It may also occur due to a combination
of factors, or less commonly may be the result of atopy. Posterior
blepharitis is caused by irregular oil production by the glands of
the eyelids (meibomian blepharitis), which create a favorable
environment for bacterial growth.[1]
Patients present with a wide array of signs and symptoms, often
signs alone.[4] Common symptoms associated with blepharitis are
burning sensation, irritation, tearing, photophobia, blurred
vision, and red eyes. Blepharitis can coexist with various
dermatological conditions including atopic dermatitis, seborrheic
dermatitis, rosacea, and eczema.[1]
Blepharitis gets difficult to manage due to its chronicity,
uncertain etiology and frequent association of ocular surface
disease. As it often coexists with other common ocular conditions,
there is a considerable overlap of symptoms adding to its
misdiagnosis or underdiagnosis.[8]
Early detection and intervention with effective and appropriate
therapy can reduce signs and symptoms of blepharitis, prevent
permanent structural damage and
INTRODUCTION
Blepharitis is one of the most common ocular disorders with
complex and multifactorial etiology that is an inflammatory disease
of the eyelid margin, often progressive and can also lead to
permanent ocular damage. It is a chronic condition that fluctuates
in severity with patients experiencing periods of exacerbations and
remissions.[1] Staphylococcus aureus, Staphylococcus epidermidis,
Propionibacterium acnes and Corynebacteria are the most common
organisms isolated from patients with chronic blepharitis.[2,3]
Anatomically blepharitis is divided into anterior blepharitis
affecting the anterior lid margin and eyelashes and posterior
blepharitis affecting the meibomian glands.[4,5] It is most
commonly seen in the middle aged but can also occur in
children.[6,7]
Anterior blepharitis is commonly caused by S. aureus
(staphylococcal blepharits) or seborrheic dermatitis
Ulcerative blepharitis in an atopic child caused by
CandidaKavitha Dasari, Harish Kumar Kasetty1Department of DVL,
Chalmeda Anand Rao Institute of Medical Sciences, Karimnagar,
1Department of DVL, Gandhi Medical College, Hyderabad, Telangana,
India
ABSTRACT
Blepharitis is a chronic inflammatory process of the eyelid
margin that fluctuates in severity with periods of exacerbations
and remissions. Burning sensation, irritation, tearing,
photophobia, blurred vision and red eyes are the common symptoms
associated. Blepharitis has been categorized into anterior and
posterior blepharitis. Blepharitis can coexist with various
dermatological conditions, and the patients may present with a wide
array of signs and symptoms. Various types of blepharitis can often
be differentiated on the basis of the appearance of the eyelid
margins. Blepharitis is difficult to manage due to uncertain
etiology and considerable overlap of symptoms that adds to its
misdiagnosis. We present a typical case of ulcerative blepharitis
in a child with atopic dermatitis, to highlight the association of
candidiasis as the cause of ulcerative type of blepharitis in
atopics.
Key words: Atopic dermatitis, blepharitis, Candida,
fluconazole
CASE REPORT
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DOI:10.4103/23197250.149430
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Dasari and Kasetty: Ulcerative blepharitis in an atopic child
caused by Candida
Indian Journal of Paediatric Dermatology | Vol 16 | Issue 1 |
January-March 2015 43
possible loss of vision, thereby improving the outcome and
reducing the disease severity.
We report a case of ulcerative blepharitis in a 12yearold female
with associated atopic dermatitis caused by candidiasis, confirmed
by simple microscopic examination of scales and successful
treatment with antifungals
CASE REPORT
A 12yearold female child was referred to us by an
ophthalmologist, with a history of mild erythema, scaling and
pruritus of the eyelid along with thick matted, hardened crusts
over the left eyelid involving upper and lower margins since 2
months without any other ocular manifestations [Figure 1]. The
patient had a history of atopic dermatitis since infancy along with
asthma and also a positive family history of atopy. On removing
these scales small, bleeding lesions masking the ulceration are
present over the upper and lower eyelid margin. On physical
examination, abnormalities were localized to the left eye, which
showed severe eyelid swelling, along with profuse lacrimation. The
left eye had an ulcer of 0.2 cm 0.5 cm in the middle portion of the
upper eyelid and another ulcer of 0.2 cm 0.3 cm involving the
middle portion of the lower eyelid [Figure 2]. The palpebral and
bulbar conjunctivae were unaffected and did not exhibit any signs
of inflammation. The sclera appeared normal, and the corneas were
clear. Even before the patient was referred to us, she was started
on a course of antibiotics along with topical steroids with no
improvement after the treatment.
We diagnosed her with ulcerative type of blepharitis and
performed a swab study to know the causative organism as she had
not previously responded to the antibiotics. Microscopic
examination of scales soaked in 10% potassium hydroxide, which
showed characteristic small, round to oval, thinwalled, clusters of
budding yeast cells (blastoconidia) and branching pseudohyphae.
Typical smooth, glabrous and white colored fungal colonies were
seen on culture with blood agar medium, suggestive of candidiasis
[Figure 3]. The patient was treated with oral fluconazole and
topical clotrimazole for 10 days, and there was rapid improvement
with complete resolution of the lesions.
DISCUSSION
Blepharitis is a chronic inflammatory process of the eyelid
margin. Burning sensation, irritation, tearing,
Figure 1: Left eye showing erythema, scaling and ulcers along
the upper and lower margin of the eyelid
Figure 2: Upper and lower margin of the eyelid of left eye
showing erythema, scaling and ulcers
Figure 3: Blood agar medium showing smooth, glabrous and white
colored fungal colonies, typical of candidiasis
photophobia, blurred vision and red eyes are the common symptoms
associated.[1]
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2015, IP: 82.145.209.116]
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Dasari and Kasetty: Ulcerative blepharitis in an atopic child
caused by Candida
Indian Journal of Paediatric Dermatology | Vol 16 | Issue 1 |
January-March 201544
Various types of blepharitis can often be differentiated on the
basis of the appearance of the eyelid margins. Staphylococcal
blepharitis is evident by mild sticking together of the lids,
thickened lid margins, missing and misdirected eyelashes.
Seborrheic blepharitis is characterized by greasy flakes or scales
around the base of eyelashes and mild redness of the eyelids.
Ulcerative blepharitis appears as matted, hard crusts around the
eyelashes that when removed, leave small sores that ooze and bleed.
There may also be a loss of eyelashes and distortion of the front
edges of the eyelids. Ulcerative blepharitis is rarely reported
because we believe that it is more commonly misdiagnosed.
We report a case of ulcerative blepharitis in a 12yearold female
with associated atopic dermatitis since childhood. Swab study
confirmed candidiasis and hence the knowledge of ulcerative
blepharitis is very important because it is a commonly overlooked
diagnosis due to its minimal manifestations. Even though the
management is simple, ulcerative blepharitis tends to have an
impact on the normal life of the child.
Although the pathophysiology of ulcerative blepharitis is not
completely understood, correlation of atopy, flares with
proliferation of Candida species and clinical response to
antifungals suggest that Candida species play a role in its
pathogenesis.[9]
HuberSpitzy et al.[9] reported a very high incidence (90.4%) of
recovery of Candida species from the lid margins of atopic patients
suffering from ulcerative blepharitis. HuberSpitzy et al.[9] also
postulated that only when Candida species happen to coincide with
severe inflammation in atopic patients will develop ulcerative
blepharitis that implies that these organisms may play an important
role in developing blepharitis of ulcerative type.
Matloob and Abbas et al.[10] also reported that blepharitis was
the most common and frequent ocular manifestation amongst atopic
dermatitis patients.
The main purpose of reporting this case is to highlight the
importance of a detailed patient history, clinical findings and a
swab study in the diagnosis of blepharitis. In most cases, the
diagnosis can be made without a swab test but knowing the causative
organism would help to provide appropriate therapy. It is,
therefore, necessary to perform a swab test in all the patients
with ulcerative blepharitis to rule out possible fungal infection
and treat adequately.
REFERENCES1. American Academy of Ophthalmology Cornea/External
Disease
Panel. Preferred Practice Pattern Guidelines Blepharitis. San
Francisco, CA: American Academy of Ophthalmology; 2008.
2. Dougherty JM, McCulley JP. Comparative bacteriology of
chronic blepharitis. Br J Ophthalmol 1984;68:5248.
3. McCulley JP, Dougherty JM. Bacterial aspects of chronic
blepharitis. Trans Ophthalmol Soc U K 1986;105 (Pt 3):3148.
4. Jackson WB. Blepharitis: Current strategies for diagnosis and
management. Can J Ophthalmol 2008;43:1709.
5. RiordanEva P, Whitcher JP. Vaughan and Asburys General
Ophthalmology. 16th ed. Newyork, NY: McGraw Hill Company, Lange;
2004. p. 1926.
6. Viswalingam M, Rauz S, Morlet N, Dart JK.
Blepharokeratoconjunctivitis in children: Diagnosis and treatment.
Br J Ophthalmol 2005;89:4003.
7. McCulley JP, Dougherty JM, Deneau DG. Classification of
chronic blepharitis. Ophthalmology 1982;89:117380.
8. Hammersmith KM, Cohen EJ, Blake TD, Laibson PR, Rapuano CJ.
Blepharokeratoconjunctivitis in children. Arch Ophthalmol
2005;123:166770.
9. HuberSpitzy V, BhlerSommeregger K, ArockerMettinger E,
Grabner G. Ulcerative blepharitis in atopic patients Is Candida
species the causative agent? Br J Ophthalmol 1992;76:2724.
10. Matloob NA, Abbas RM. Ocular manifestations in atopic
dermatitis patients and their relation to disease severity. Iraqi J
Community Med 2011;1:204.
How to cite this article: Dasari K, Kasetty HK. Ulcerative
blepharitis in an atopic child caused by Candida. Indian J Paediatr
Dermatol 2015;16:42-4.
Source of Support: Nil, Conflict of Interest: Nil
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