Most periorbital swelling with redness is preseptal cellulitis that settles with oral or intravenous antibiotics. Necrotising fasciitis of the eyelids is rare but progresses within hours.
The warning signs are pain out of proportion to the appearance, violaceous or dusky skin, bullae, anaesthesia of the skin, rapid spread and systemic toxicity. These call for urgent senior review, blood tests including a LRINEC score, broad-spectrum antibiotics and early surgical assessment rather than a trial of oral treatment.
- Ask about pain severity and check skin sensation in any periorbital cellulitis.
- Look for dusky or violaceous skin, bullae and rapid spread.
- Check vision, pupils and eye movements to exclude orbital involvement.
- Escalate immediately if red flags are present; do not send home on oral antibiotics.
Why it matters
Hours matter in necrotising fasciitis, and early signs are easy to mistake for simple cellulitis.
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