What is the treatment for blepharitis?

Treatment of Blepharitis

The cornerstone of blepharitis treatment is daily eyelid hygiene with warm compresses and eyelid cleansing, which should be maintained long-term as a cure is usually not possible. 1

Understanding Blepharitis

Blepharitis is a chronic inflammatory condition affecting the eyelid margins that can be classified as:

• Anterior blepharitis: Affects eyelid skin, base of eyelashes, and follicles
• Posterior blepharitis: Involves meibomian glands (also called Meibomian Gland Dysfunction or MGD)

First-Line Treatment Algorithm

1. Eyelid Hygiene (Essential for all types)

• Warm compresses: Apply to eyelids for several minutes daily to:

  • Soften crusts and scales (anterior blepharitis)
  • Warm meibomian secretions (posterior blepharitis/MGD)
  • Use hot tap water on clean washcloth, over-the-counter heat pack, or homemade bean/rice bag heated in microwave
  • Important: Avoid temperatures that could burn skin

• Eyelid cleansing: Perform after warm compresses

  • For anterior blepharitis: Gently rub base of eyelashes using either:
    • Diluted baby shampoo on cotton swab/pad/clean fingertip
    • Commercial eyelid cleanser
    • Hypochlorous acid 0.01% cleaners (strong antimicrobial effect)
  • For posterior blepharitis: Include vertical eyelid massage to express meibomian glands

• Frequency: Once or twice daily, consistently maintained long-term

2. Topical Treatments

• Topical antibiotics for moderate to severe cases:

  • Bacitracin or erythromycin ointment applied to lid margins 1-3 times daily 2
  • Apply directly after removing all scales and crusts
  • Use intermittently to prevent resistance development

• Artificial tears to manage associated dry eye symptoms 1

• Topical perfluorohexyloctane for tear film stabilization 1

3. Additional Therapies for Refractory Cases

• Topical anti-inflammatory agents:

  • Corticosteroids for marked inflammation (short-term use)
  • Cyclosporine for chronic inflammation

• Systemic antibiotics for severe MGD:

  • Tetracyclines
  • Azithromycin (caution with cardiovascular patients)

• Antiparasitic medications for Demodex blepharitis:

  • Metronidazole
  • Ivermectin
  • Lotilaner 1, 3

• In-office procedures for persistent MGD:

  • Vectored thermal pulsation
  • Microblepharoexfoliation 1

Special Considerations

Cautions

• Manual dexterity: Assess patient's ability to perform eyelid hygiene safely
• Neurotrophic corneas: Provide proper counseling to avoid corneal epithelial injury
• Advanced glaucoma: Advise against aggressive lid pressure which may increase eye pressure
• Pre-surgical management: Address moderate to severe blepharitis before intraocular surgery to reduce endophthalmitis risk

Treatment Resistance

If blepharitis does not respond to standard therapy, consider:

• Carcinoma masquerading as blepharitis
• Immune-mediated diseases (especially with eyelash loss or conjunctival cicatricial changes)
• Demodex infestation (pathognomonic collarettes at base of lashes)

Patient Education

• Emphasize that blepharitis is typically chronic and not permanently curable
• Treatment success depends on consistent daily compliance
• Symptoms often recur when treatment is discontinued
• Long-term maintenance therapy is usually required

By following this systematic approach to blepharitis management, patients can achieve significant symptom relief and prevent potential complications such as corneal damage and vision loss.