What are the treatment options for blepharitis?

Treatment Options for Blepharitis

The foundation of blepharitis treatment is daily eyelid hygiene with warm compresses and gentle cleansing, combined with targeted therapies based on the type and severity of blepharitis. 1, 2

First-Line Treatment: Eyelid Hygiene

Warm Compresses

• Apply for 10-15 minutes, 3-4 times daily 2
• Use hot tap water on a clean washcloth, over-the-counter heat pack, or homemade bean/rice bag heated in the microwave 1
• Particularly helpful for posterior blepharitis/meibomian gland dysfunction (MGD) 1
• Caution: Ensure compresses are not hot enough to burn the skin 1

Eyelid Cleansing

• Gently rub the base of eyelashes using:
  • Diluted baby shampoo
  • Commercially available eyelid cleaner
  • Hypochlorous acid 0.01% cleaners (strong antimicrobial effect) 1
• Use a pad, cotton ball, cotton swab, or clean fingertip 1
• For anterior blepharitis: Focus on removing crusting from eyelashes 1
• For posterior blepharitis: Include vertical eyelid massage to express meibomian gland secretions 1

Second-Line Treatment: Topical Medications

Topical Antibiotics

• Bacitracin or erythromycin ointment applied to eyelid margins once or more daily for 5-7 days 2
• Effective for decreasing bacterial load on the eyelid margin 1

Topical Anti-inflammatory Agents

• Short-term use of topical corticosteroids for marked inflammation 1, 2
• Loteprednol etabonate 0.5%/tobramycin 0.3% combination for moderate to severe cases (safer than dexamethasone-containing products) 2
• Cyclosporine may be beneficial in some cases 1

Other Topical Treatments

• Topical perfluorohexyloctane (FDA approved in 2023) - prevents tear evaporation and improves symptoms 1
• Topical ketoconazole cream 2% applied twice daily for four weeks (for seborrheic dermatitis causing blepharitis) 2

Third-Line Treatment: Systemic Medications

Oral Antibiotics

For severe cases or when topical treatments are insufficient:

• Dicloxacillin: 500 mg four times daily 2
• Cephalexin: 500 mg four times daily 2
• Clindamycin: 300-450 mg three times daily 2

Antiparasitic Medications

For Demodex-related blepharitis:

• Metronidazole
• Ivermectin
• Lotilaner 1

Fourth-Line Treatment: In-Office Procedures

• Vectored thermal pulsation
• Microblepharoexfoliation 1
• Intralesional steroid injection or incision and curettage for persistent chalazia 2

Treatment Duration and Maintenance

• Patient must understand that blepharitis is typically chronic and often requires long-term management 1
• Initial treatment should be reassessed after 2-4 weeks 2
• Regular maintenance therapy is often needed to prevent recurrence 2

Special Considerations

Safety Precautions

• Ensure patient has adequate manual dexterity to perform eyelid hygiene safely 1, 2
• Patients with advanced glaucoma should avoid aggressive lid pressure (can increase eye pressure) 1
• Patients with neurotrophic corneas need special care to avoid corneal epithelial injury 1
• Use topical corticosteroids with caution and only for short periods 2

Pre-Surgical Management

• Control moderate to severe blepharitis prior to intraocular surgery to reduce risk of postoperative endophthalmitis 1
• Blepharitis is a risk factor for endophthalmitis after intravitreal injection and bleb-related infection 1

Prevention of Recurrence

• Continue regular eyelid hygiene
• Remove eye makeup completely 2
• Treat underlying conditions (seborrheic dermatitis, rosacea, etc.) 2
• Consider replacement of contact lenses and case after resolution if applicable 2

Blepharitis treatment often requires persistence and a trial-and-error approach to find the optimal regimen for each case. The combination of consistent eyelid hygiene with appropriate medical therapy based on the type and severity of blepharitis offers the best chance for symptom control and improved quality of life.