Problem refinement

At this point dermatitis, in its various forms, has still not been fully excluded. Cosmetics are an obvious cause of contact dermatitis. You ask Louise about the products she uses but she cannot think of any time where her make-up or facial products have caused her symptoms to flare up. 

To determine if either allergy or seborrhoeic dermatitis are the cause, further questions are needed. To explore atopy, asking about personal or family history of asthma, eczema or hay fever is needed as well as knowing about other areas of skin involvement if you are to consider seborrhoeic dermatitis as a possible cause.

Louise reports no history of other medical problems and does not report any skin issues. This helps to rule out acne rosacea as a cause, as this can cause blepharitis-like symptoms. It appears that dermatitis is not the cause of her symptoms and blepharitis is the differential diagnosis.

Red flags

Other possible causes can be excluded based on age and findings. For example, ectropion, entropion and seborrhoeic keratosis are associated with older age, as are malignant causes. Visual inspection does not reveal any lesions or growths, thus further eliminating malignancy, as well as conditions such as chalazion, hordeola, hydrocystoma and xanthelasma. 

Lacrimal duct/sac issues are most common in younger people, as is molluscum contagiosum. Finally, no swelling or redness of orbital tissues is noted, so ruling out periorbital and orbital cellulitis (and this would be an acute presentation).

Management : Self-care options

The mainstay of treatment for blepharitis is improved lid hygiene and warm compresses. Treatment of blepharitis is a long-term procedure and it may take several weeks to see improvement. As it is a chronic problem, eyelid hygiene may need to be continued indefinitely.

Prescribing options

If lid hygiene measures are ineffective, then application of topical antibiotics may be tried, although previous use of chloramphenicol failed to resolve symptoms in this case. If unresponsive, a systemic antibiotic could be prescribed.

Safety netting

Louise should be told that blepharitis is a chronic problem that is associated with flare-ups and remission, and that any treatment is not curative.  Advise her to return to the pharmacy after four weeks to see if her symptoms have improved.