What is the treatment for blepharitis?

Blepharitis Treatment

The cornerstone of blepharitis treatment is a combination of warm compresses and eyelid cleansing, which should be performed daily as first-line therapy for all patients with blepharitis. 1, 2

First-Line Treatment

• Warm compresses

  • Apply to eyelids for several minutes (10-15 minutes, 3-4 times daily)
  • Helps soften adherent scales, discharge, and warm meibomian secretions
  • Can be achieved using hot tap water on a clean washcloth, over-the-counter heat pack, or homemade bean/rice bag heated in microwave
  • Important: Instruct patients to avoid temperatures that could burn the skin

• Eyelid cleansing

  • Gentle massage of eyelids
  • Vertical massage to express meibomian secretions (especially for posterior blepharitis/MGD)
  • Side-to-side rubbing of eyelid margins to remove crusting from eyelashes
  • Can be performed using:
    • Diluted baby shampoo
    • Commercially available eyelid cleaners
    • Hypochlorous acid 0.01% (strong antimicrobial effect)
  • Apply using pad, cotton ball, cotton swab, or clean fingertip

Second-Line Treatment

• Topical antibiotics (when signs of infection are present)

  • Bacitracin or erythromycin ointment applied directly to lid margins 1-3 times daily 3
  • Particularly effective for anterior blepharitis
  • Should be applied after removing all scales and crusts 3

• Topical anti-inflammatory agents (for moderate to severe inflammation)

  • Corticosteroids (short-term use)
  • Combination antibiotic/steroid preparations

Advanced Treatments

• Topical perfluorohexyloctane (FDA approved in 2023)

  • Prevents tear evaporation
  • Improves symptoms and corneal staining in patients with dry eye disease 1

• For Demodex blepharitis

  • Lotilaner ophthalmic solution 0.25% has shown promise in clinical trials 4
  • Can eradicate Demodex mites and eliminate collarettes and eyelid redness

Treatment Algorithm

1. All patients: Daily warm compresses + eyelid cleansing/massage
2. If signs of infection: Add topical antibiotic ointment
3. For moderate-severe inflammation: Consider short-term topical steroid or combination antibiotic/steroid
4. For MGD component: Emphasize vertical lid massage and meibomian gland expression
5. For persistent symptoms: Consider newer therapies like perfluorohexyloctane

Important Considerations and Pitfalls

• Patient education is crucial

  • Treatment is typically long-term; symptoms often recur when treatment is discontinued 1, 2
  • Once or twice daily warm compresses and massage is generally adequate

• Safety precautions

  • Patients with advanced glaucoma should avoid aggressive lid pressure during massage 1
  • Patients with neurotrophic corneas need careful counseling to avoid corneal epithelial injury 1
  • Consider patient's manual dexterity and ability to safely perform eyelid cleansing

• Treatment approach may differ based on blepharitis type

  • Eyelid cleansing is especially useful for anterior blepharitis
  • Warm compresses are especially helpful for posterior blepharitis/MGD 1

• Underlying conditions

  • Consider treating associated conditions like rosacea, seborrheic dermatitis, or diabetes 2, 5
  • Contact lens wearers should discontinue lens wear until symptoms resolve 2

The evidence consistently shows that while blepharitis cannot be permanently cured, symptoms can be effectively managed with consistent application of these treatments 6, 5, 7. The optimal regimen often requires persistence and a trial-and-error approach tailored to the specific type and severity of blepharitis 1.