What is the treatment for blepharitis?

Treatment of Blepharitis

The first-line treatment for blepharitis is a combination of daily warm compresses and eyelid hygiene, which should be performed consistently as the cornerstone of management. 1

Treatment Algorithm for Blepharitis

First-Line Therapy (All Patients)

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

Second-Line Therapy (Signs of Infection)

• Topical antibiotics: Bacitracin or erythromycin ointment
  • Application: Apply directly to lid margins 1-3 times daily 1, 2
  • Duration: Continue for 5-7 days 1

Third-Line Therapy (Moderate to Severe Cases)

• Combination antibiotic/steroid topical treatment 1, 3
  • Particularly effective when significant inflammation is present
  • Short-term use to avoid steroid-related complications

Fourth-Line Therapy (Persistent Cases)

• For persistent chalazia: Consider intralesional steroid injection or incision and curettage if persisting >2 months 1
• For severe cases: Oral antibiotics may be necessary
  • Adults: Doxycycline or minocycline
  • Children <8 years: Oral erythromycin (due to tetracycline contraindication) 4

Type-Specific Management

Anterior Blepharitis (Affecting Skin and Lashes)

• Often staphylococcal and/or seborrheic in nature 5
• Focus on thorough eyelid cleansing with commercial lid scrubs or diluted baby shampoo 6
• Topical antibiotics applied directly to lid margins

Posterior Blepharitis/Meibomian Gland Dysfunction

• Requires more aggressive warm compress therapy to melt thickened meibum 6
• Eyelid massage following warm compresses to express glands
• Consider in-office thermal pulsation treatments for refractory cases 6

Demodex Blepharitis

• Identified by characteristic collarettes at base of eyelashes 7
• Recently approved treatment: Lotilaner ophthalmic solution 0.25% 7
• Can eradicate Demodex mites in 50-67% of patients with short-term treatment

Important Clinical Considerations

• Long-term management is essential: Blepharitis is typically chronic with no definitive cure 5, 3
• Patient education is crucial: Emphasize that treatment is long-term and symptoms often recur when treatment is discontinued 1
• Underlying conditions: Treat associated dermatological conditions like seborrheic dermatitis, rosacea, and eczema 5
• Contact lens wearers: Discontinue contact lens wear until symptoms resolve; replace lenses and case after resolution 1

Common Pitfalls to Avoid

1. Inadequate treatment duration: Blepharitis requires consistent, long-term management
2. Overuse of steroids: Can lead to glaucoma, cataracts, or secondary infections
3. Neglecting underlying conditions: Failure to address associated dermatological conditions
4. Poor patient compliance: Simplified regimens improve adherence
5. Missing Demodex infestation: Look specifically for collarettes at the base of eyelashes 7

The American Academy of Ophthalmology strongly emphasizes that eyelid hygiene and warm compresses remain the foundation of treatment for all forms of blepharitis, regardless of severity or subtype 1, 6.