Preseptal Cellulitis Treatment

A 16 year old patient presents with a history of multiple hordeola that now appears as a preseptal cellulitis, what medications are best for the treatment?

Step one in all cases of a potential preseptal cellulitis is to rule out an orbital cellulitis. That is to ensure that the patient has full EOM’s, is not experiencing diplopia, there is no pain on eye movement and no relative afferent pupillary defect (RAPD). Once that’s confirmed, then treatment for a preseptal cellulitis requires oral medications. The best options are medications that work well with soft tissue:

1. Augmentin 875mg BID (or 500mg TID) provided the patient is not allergic to penicillin. Another contraindication – especially to the 875mg pill is a patient that has difficulty swallowing pills as these are large pills.
2. Keflex 500mg BID. This is a cephalosporin and their is the rare potential of a cross reaction to people who are allergic to penicillin. It seems to work well but due to it’s effectiveness in soft tissue disorders.
3. Bactrim mg BID. Patients with sulpha allergies would be contraindicated and this medication would typically be used if MRSA is cultured, diagnosed or highly suspected.
4. Doxycycline 100mg BID. Although contraindicated in pregnant or nursing women and perhaps even in women of child bearing age, this medication may also help due to it’s strong anti-inflammatory properties.
5. Azithromycin – 5 day Z-pack. This may be an option if most of the above medications are contraindicated and could help with the condition.

Keep in mind that all of these medications (with the exception of the Z-pack being 5 days) should be used for the entire 7 consecutive days even if the condition resolves sooner. It is also important to look for preseptal cellulitis in children who present with a conjunctivitis. A reddish sheen around the eye is a clear indication of preseptal cellulitis. Because Haemophilus influenza is such a common pathogen in childhood conjunctivitis and is prone to preseptal cellulitis, clinicians should be on the look out for it.

Written by: Paul M. Karpecki, OD, FAAO, Clinical Director – PECAA