What is the treatment for blepharitis?

Blepharitis Treatment

The first-line treatment for blepharitis is a combination of daily warm compresses (10-15 minutes, 3-4 times a day) and eyelid hygiene with gentle massage, as recommended by the American Academy of Ophthalmology. 1

Treatment Algorithm

First-Line Therapy

• Warm compresses: Apply for 10-15 minutes, 3-4 times daily
• Eyelid hygiene: Carefully remove all scales and crusts
• Gentle massage: To express meibomian glands (especially for posterior blepharitis)

Second-Line Therapy

• Add topical antibiotics when signs of infection are present:
  • Bacitracin ointment: Apply directly to lid margins 1-3 times daily 2
  • Erythromycin ointment: Alternative option for lid margin application

Third-Line Therapy

• Combination antibiotic/steroid topical treatments for moderate to severe cases 1
• Consider based on inflammation severity and response to initial therapy

Fourth-Line Therapy

• For persistent (>2 months) or large chalazia:
  • Intralesional steroid injection
  • Incision and curettage 1

Type-Specific Management

Anterior Blepharitis

• Primarily requires eyelid hygiene and topical antibiotics 1, 3
• Focus on removing debris from eyelash base

Posterior Blepharitis/Meibomian Gland Dysfunction (MGD)

• Warm compresses are essential
• Meibomian gland expression
• May require oral antibiotics in severe cases 1, 3
• In-office thermal pulsation treatments may be beneficial 3

Demodex Blepharitis

• Affects approximately 25 million Americans 4
• Identified by collarettes (pathognomonic) at base of eyelashes 4, 5
• Recently FDA-approved: lotilaner ophthalmic solution 0.25% 5
  • Shown to eradicate Demodex mites in 50-67% of patients
  • Demonstrates continued benefits through 1 year of follow-up

Important Clinical Considerations

• Blepharitis is a chronic condition requiring long-term management 1, 6
• Patient education is crucial as symptoms often recur when treatment is discontinued 1
• Associated conditions to address:
  • Rosacea
  • Seborrheic dermatitis
  • Dry eye disease 6, 7

Prevention and Maintenance

• Consistent eyelid hygiene
• Complete removal of eye makeup
• Treatment of underlying conditions 1
• Contact lens wearers should:
  • Discontinue lens wear until symptoms resolve
  • Replace lenses and case after resolution 1

Referral Indications

• Persistent styes (lasting >2 months)
• Development of chalazia
• Aggressive infections with signs of systemic toxicity 1
• Special consideration for patients with advanced glaucoma or neurotrophic corneas 1

Common Pitfalls

1. Inadequate duration of warm compresses - Ensure full 10-15 minutes for effective treatment
2. Inconsistent treatment - Emphasize the chronic nature requiring ongoing management
3. Failure to identify specific type - Different types require tailored approaches
4. Missing underlying conditions - Always assess for associated dermatological or systemic diseases
5. Premature discontinuation - Treatment needs to be continued long-term, even after symptom improvement 6