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: kavithakondepati@gmail.com

(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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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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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.

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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.

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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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