Sore, crusty eyelids in a child that keep coming back

Key takeaways

Sore, flaky lid margins that settle and return are blepharitis, inflammation of the strip where the lashes and the oil glands sit.
Recurrent lumps on the lids come from the same inflamed oil glands, so treating each lump alone never stops the next one.
Dislike of bright light, watering and a gritty eye mean the inflammation has reached the cornea, and that is what turns a nuisance into a sight problem.
Daily lid cleaning is the treatment, and it has to continue after the eyes look completely well.
Most children improve as they get older, but the years while it is active are the years vision is still developing, so it is worth treating properly now.

There is a particular file that arrives on my desk two or three times a month. The child is four or five. She has had four courses of drops from four different places. Somebody said conjunctivitis, somebody said ketumbit, somebody said allergy, and each time it settled for a fortnight and came back. The mother has stopped expecting an answer and is now mainly apologising for taking up my time.

She is not wasting my time. That pattern is the diagnosis. A child whose lid margins are sore and crusty again and again, whose eyes water and redden for weeks at a stretch, and who keeps growing lumps on the lids, is not having a run of bad luck. She has lid margin disease, and the reason I want to see her is not the lids. It is the cornea underneath.

My child's eyelids are crusty every morning. Is that normal?

Not if it happens most mornings. A single gummy morning after a cold is ordinary. Weeks of flakes and crusts along the roots of the lashes, lids that stick together on waking, sore and itchy eyelid edges and a gritty feeling all day is blepharitis, which simply means inflammation of the lid margin.

The lid margin is a busy strip of tissue. Lashes come out of it, and so do the openings of dozens of tiny oil glands, the meibomian glands, whose oil keeps the tear film from evaporating off the eye. When that strip becomes inflamed, the oil turns thick and the openings block, the lashes collect debris, and the surface of the eye loses the oily layer that was protecting it. Everything that follows comes from those two facts.

The other thing to know early is that blepharitis comes and goes. Symptoms flare and settle and flare again, which is exactly why families end up with four half-used bottles in the fridge. Each bottle looked like it worked, because the flare was going to settle anyway.

Why does she keep getting lumps on the same eyelid?

Because the glands that make the lumps are the glands that are inflamed. A chalazion is a swollen bump that forms when one of those oil glands clogs and the trapped oil sets off inflammation in the lid. Inflamed eyelids sit near the top of the list of reasons a child gets them, so a child with blepharitis is a child whose glands are primed to block, and one lump clearing tells you nothing about the next.

This is where a lot of families get stuck, because the lump is what you can see and the lid margin disease is what you cannot. Warm compresses and patience clear the individual lump. They do nothing about the state of the lid that produced it. The basics of styes and chalazia, the compress technique, why you must never squeeze one, and when a lump needs a procedure, are all in that article, and I am not going to repeat them here. This article is for the child on her fourth lump.

One lump is bad luck. The fourth lump is a diagnosis.

Why does he screw up his eyes in bright light?

Because the front surface of his eye is inflamed too, and that is the part of this condition I actually worry about. When lid margin disease starts involving the cornea, the clear window at the front of the eye, doctors call it blepharokeratoconjunctivitis. It is a long word for a simple idea: the lids, the white of the eye and the cornea are all caught up in the same inflammation.

The signs a parent notices are dislike of bright light, watering, redness that keeps returning, discharge and a child who says the eye feels gritty or rubs at it constantly. In a hospital series of children referred to a corneal clinic in London, most had visible changes on the surface of the cornea and a small number had corneal ulcers. Those were the severe end, the children ill enough to reach a corneal specialist, so please do not read that as your child's risk. Read it as my reason for looking carefully at every child whose lids keep flaring, because inflammation on the cornea is how a nuisance turns into a sight problem.

The other number from that series is the one I think about most. Symptoms usually started around age four, the children were around five when they were finally seen, and the diagnosis had typically been missed for many months while other things were tried. Nobody was careless. The condition is simply good at imitating ordinary pink eye over and over again.

How do I clean a four-year-old's eyelids without a fight?

Make it boring, make it short, and attach it to something she already does. Lid hygiene is the treatment, not the preparation for the treatment, and it works when it is done daily and keeps being done after everything looks fine.

The method is the same one used for adults, scaled down. Soak a clean flannel or cotton wool in warm water and hold it against the closed lid for a few minutes. Massage the lids gently for around half a minute. Then wipe along the lid edge, right where the lashes come out, with cotton wool to lift off the crusts. A doctor may suggest a diluted cleaning solution rather than plain warm water. Ask which one, rather than reaching for whatever is in the bathroom.

The practical trick is timing. Do it at bath time, when a warm wet cloth on the face is already normal, or in front of a screen if that buys you ninety compliant seconds. Do one eye per song. Let her hold the cloth herself once she is old enough to want control. And when the eyes look completely well, keep going, because stopping is the single commonest reason it comes straight back. This is a condition you manage rather than one you finish.

What will the doctor do beyond cleaning?

Look at the cornea, first and properly. That is the part a parent cannot do at home and the part that decides how hard we treat. I use a slit lamp, a microscope on a stand, and for a small child that often means sitting on your lap with your hands over hers. If she will not tolerate it, there are other ways to see enough, and a young child can be examined and measured long before she can cooperate on request.

Treatment then follows severity. Milder disease is lid hygiene with a topical antibiotic added for a course. More severe disease, especially where the cornea is involved, needs a longer and more systemic approach, and sometimes a carefully supervised anti-inflammatory drop. I am naming categories rather than medicines on purpose. Which drug, what strength and for how long depends on the eye in front of me, and steroid drops in particular are not something to borrow from a sibling or repeat from an old prescription. A lump that keeps returning in exactly the same spot on the lid is also a reason for a closer look rather than another compress.

Will my child grow out of it?

Most children improve as they get older. In that London series, the disease carrying on past the age of eight was uncommon, and children were typically discharged around nine or ten after years of follow-up. That is genuinely reassuring, and it is not a promise about your child, because a hospital series is a group and your daughter is one person.

What I would rather you took from it is this. The years between four and eight are the years the treatment has to cover, and they are the years a child's vision is still developing. That is a good argument for treating it properly now rather than riding it out. The adult version of the same problem is a longer story about oil glands, dry eye and rosacea, and the oculoplastic surgeon Dr Catherine Chow explains what anterior and posterior lid margin disease means in an adult, and why it is managed rather than cured.

For now: clean the lids daily, keep cleaning them when the eyes look fine, and get the cornea checked by someone who will actually look at it. A lid that turns hot, tight and swollen rather than simply crusty is a different problem again, and a swollen eyelid carries its own short list of same-day signs. Pain, light sensitivity that does not settle, or any change in how well your child sees moves this from a routine appointment to a prompt one. Most of these children do very well. The ones who do best are the ones whose parents were told what they were treating.

See a doctor promptly if…

Your child's eye is painful, not just itchy or gritty.
Bright light is genuinely distressing, or the light sensitivity does not settle between flares.
The eye is very red, or the redness has not cleared in weeks.
Vision has changed, or your child has started closing one eye to see.
The eyelid becomes hot, tight and swollen, or the redness spreads onto the cheek.
A lump keeps returning in exactly the same spot on the lid.

Common questions

Is blepharitis in children caused by poor hygiene at home?

No, and I want that said plainly because parents blame themselves for this one. It is an inflammation of the lid margin and the oil glands in it, not dirt. Clean children get it. Daily lid cleaning is the treatment because it clears the debris the inflammation produces, not because anyone did anything wrong.

Is it contagious? Can she still go to tadika?

Blepharitis itself is not passed from child to child, so tadika and school carry on as normal. An episode of red, sticky conjunctivitis on top of it is a different question, and that one depends on what the infection is. If the eye is newly red and gluey rather than simply flaring, ask before sending her in.

How long does the lid cleaning have to go on for?

Longer than feels reasonable. The line I repeat in clinic is to keep cleaning the lids even after the symptoms have cleared up, because stopping when things look good is the commonest reason a child is back three weeks later. Think of it as tooth brushing for the eyelids rather than a course of treatment with an end date.

Can sore eyelids actually damage her eyes?

The lids themselves, no. The cornea is the part that can be damaged, and in children with long-standing lid margin disease the surface of the cornea can become inflamed, scarred, or in a small number of cases ulcerated. That is uncommon and it is treatable, and it is precisely why I want to look rather than treat by description.

The drops from the clinic worked, so why did it come back?

Because the drops treated the flare and the flare was going to settle anyway. Blepharitis is a condition where symptoms come and go by nature, so almost anything appears to work once. What changes the pattern is daily lid care kept up between flares, with medicines added by the doctor when the eye needs them.

Does she need to see an eye doctor, or is a GP enough?

A GP or a klinik kesihatan is a reasonable first stop for one episode. A child on her third or fourth round, or any child with light sensitivity, pain or a red eye that will not clear, should see an eye doctor, because the examination that matters here is a magnified look at the cornea and that needs the equipment.

Will my child need surgery for the lumps?

Usually not. Most lid lumps in children settle with warm compresses and time, and in a young child a procedure means a general anaesthetic, which is a good reason to be patient. A lump that is large, that is pressing on the eye and blurring it, or that keeps returning in the same place is worth reviewing rather than waiting on.

References

Blepharokeratoconjunctivitis in children: diagnosis and treatment (Moorfields corneal clinic series, PMC) · pmc.ncbi.nlm.nih.gov
NHS · Blepharitis · www.nhs.uk
AAPOS · Chalazion · aapos.org
American Academy of Ophthalmology · What are chalazia and styes · www.aao.org
American Academy of Ophthalmology · Child eye problems parents should never ignore · www.aao.org

By Dr Chan Li Yen. General information only. It does not replace a consultation. If you are worried about your child's eyes or vision, please see an eye doctor.