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 the condition is typically chronic with no definitive cure. 1

First-Line Treatment: Eyelid Hygiene

Warm Compresses

• Apply warm compresses to eyelids for 10-15 minutes, 1-2 times daily 1
• Use hot tap water on clean washcloth, over-the-counter heat pack, or homemade bean/rice bag heated in microwave
• Ensures proper temperature (warm but not hot enough to burn skin)
• Helps soften crusts, scales, and discharge
• Warms meibomian secretions to improve flow

Eyelid Cleansing

• Follow warm compresses with gentle eyelid cleansing:
  • Use diluted baby shampoo or commercial eyelid cleaner on cotton ball, pad, cotton swab, or clean fingertip 1
  • Gently rub the base of eyelashes to remove crusting
  • For anterior blepharitis: focus on removing crusts from eyelashes
  • For posterior blepharitis/MGD: perform vertical eyelid massage to express meibomian glands 1

Important Considerations

• Eyelid hygiene should be performed daily or several times weekly long-term 1
• Caution patients with advanced glaucoma to avoid aggressive pressure on eyelids 1
• Patients with neurotrophic corneas need careful counseling to avoid epithelial injury 1
• Symptoms typically recur when treatment is discontinued 1

Second-Line Treatment: Topical Medications

Topical Antibiotics

• For moderate to severe cases or when symptoms persist despite eyelid hygiene:
  • Bacitracin or erythromycin ointment applied to eyelid margins 1-3 times daily for a few weeks 1, 2
  • Apply directly to lid margins after removing all scales and crusts 2
  • Rotate different antibiotics to prevent resistance development 1

Topical Anti-inflammatory Agents

• For marked inflammation:
  • Topical corticosteroids for short-term use 1
  • Topical cyclosporine for longer-term management 1
  • Topical perfluorohexyloctane (FDA-approved in 2023) 1

Third-Line Treatment: Systemic Medications

Oral Antibiotics

• For severe, persistent posterior blepharitis/MGD not responding to topical treatments:
  • Doxycycline, minocycline, or tetracycline daily, tapered after clinical improvement 1
  • Erythromycin or azithromycin for children and pregnant women 1
  • These medications have both antimicrobial and anti-inflammatory properties 1

Important Precautions with Oral Antibiotics

• Tetracyclines:
  • Contraindicated in pregnancy, nursing women, and children under 8 years 1
  • Can cause photosensitization, GI upset, vaginitis 1
  • May interact with other medications (oral contraceptives, warfarin) 1
  • Minocycline can stain skin, nails, teeth, and other tissues 1
• Azithromycin:
  • Use with caution in patients with cardiovascular disease 1

Special Considerations

Type-Specific Approach

• Anterior blepharitis (staphylococcal/seborrheic): Focus on eyelid cleansing and topical antibiotics 1, 3
• Posterior blepharitis/MGD: Emphasize warm compresses and meibomian gland expression 1, 3

Pre-Surgical Management

• Address moderate to severe blepharitis before intraocular surgery to reduce endophthalmitis risk 1
• Control symptoms and signs with topical antibiotics and eyelid hygiene 1

Common Pitfalls to Avoid

• Setting unrealistic expectations: Inform patients that blepharitis is typically chronic with no definitive cure 1, 4
• Inadequate treatment duration: Eyelid hygiene must be continued long-term 5
• Excessive pressure during eyelid massage in glaucoma patients 1
• Prolonged topical steroid use without monitoring 4
• Failure to recognize underlying conditions (rosacea, seborrheic dermatitis) 5, 6

By following this structured approach to blepharitis management, focusing first on consistent eyelid hygiene and escalating to topical and systemic treatments as needed, most patients will experience significant symptom relief and improved quality of life, even though the condition typically requires ongoing management.