What are the treatment options for blepharitis?

Treatment Options for Blepharitis

The cornerstone of blepharitis treatment is daily eyelid hygiene, including warm compresses and eyelid cleansing, which should be maintained long-term as blepharitis is typically chronic with no definitive cure. 1, 2

First-Line Treatment: Eyelid Hygiene

• Warm compresses: Apply to eyelids for several minutes to soften adherent scales and warm meibomian secretions

  • Use hot tap water on a clean washcloth, over-the-counter heat pack, or homemade bean/rice bag
  • Apply for 5-10 minutes once or twice daily
  • Caution: Avoid temperatures hot enough to burn skin

• Eyelid cleansing:

  • Gently rub the base of eyelashes using diluted baby shampoo or commercial eyelid cleanser on a pad, cotton ball, cotton swab, or clean fingertip
  • Rub eyelid margins from side to side to remove crusting from eyelashes
  • Eye cleaners with hypochlorous acid (0.01%) have strong antimicrobial effects for both anterior and posterior blepharitis
  • For posterior blepharitis/MGD: Perform vertical eyelid massage to express meibomian secretions

• Artificial tears: May provide symptomatic relief, especially when dry eye is present

Second-Line Treatment (if inadequate response after 2-4 weeks)

Topical Antibiotics

• Bacitracin ointment: Apply directly to lid margins 1-3 times daily after carefully removing all scales and crusts 3
• Erythromycin ointment: Applied to eyelid margins once or more times daily
• Antibiotic-steroid combinations: Such as loteprednol etabonate 0.5%/tobramycin 0.3% suspension for short-term use

Topical Anti-inflammatory Agents

• Corticosteroids: Brief courses for acute flares (use with caution and monitor for corneal ulceration)
• Cyclosporine: May be helpful, especially when associated with dry eye

Third-Line Treatment (for severe, persistent cases)

Oral Antibiotics

• Tetracyclines (doxycycline, minocycline, tetracycline):

  • Reserved for severe, persistent posterior blepharitis/MGD not responding to eyelid hygiene and topical treatments
  • Work through both antimicrobial and anti-inflammatory mechanisms
  • Contraindicated in pregnancy, nursing women, children under 8 years
  • Treatment duration: 1-3 months, then reassess

• Macrolides (erythromycin, azithromycin):

  • Alternative for women of childbearing age and children
  • Azithromycin: 500mg daily for 3 days in three cycles with 7-day intervals, or 1g weekly for 3 weeks
  • Erythromycin for children: 30-40 mg/kg divided over 3 doses for 3 weeks, then twice daily for 4-6 weeks

Advanced Treatments

• In-office procedural treatments:
  • Vectored thermal pulsation
  • Microblepharoexfoliation
  • Particularly helpful for meibomian gland dysfunction

Special Considerations

• Pre-surgical management: Address moderate to severe blepharitis before intraocular surgery to reduce endophthalmitis risk 1
• Drug-induced blepharitis: Discontinue the suspected causative medication if medically appropriate 2
• Demodex blepharitis: May require antiparasitic medications (metronidazole, ivermectin, lotilaner) 1

Patient Education Points

• Blepharitis is typically chronic with no definitive cure; daily treatment can significantly improve symptoms but must be continued long-term 1, 2
• Consistent daily eyelid hygiene is essential for symptom control
• Avoid excessive pressure during eyelid massage, especially in patients with glaucoma 2
• Caution with contact lens wear to prevent cross-contamination between eye, lens, solutions, or cases 4

Monitoring and Follow-up

• Reassess after 2-4 weeks of initial eyelid hygiene
• If inadequate response, add topical antibiotics
• For persistent posterior blepharitis/MGD despite above measures, consider oral antibiotics
• Monitor for potential side effects of medications, particularly with tetracyclines and macrolides 2