What is the treatment for blepharitis?

Treatment 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

First-Line Treatment: Eyelid Hygiene

• Warm compresses: Apply for 10-15 minutes, 3-4 times daily 1

  • Use hot tap water on a clean washcloth, over-the-counter heat pack, or homemade bean/rice bag heated in the microwave
  • Particularly helpful for posterior blepharitis/meibomian gland dysfunction (MGD)

• Eyelid cleansing: Gently rub the base of eyelashes using: 1

  • Diluted baby shampoo
  • Commercially available eyelid cleaners
  • Hypochlorous acid 0.01% cleaners
  • Use a pad, cotton ball, cotton swab, or clean fingertip

• Technique variation by type:

  • For anterior blepharitis: Focus on removing crusting from eyelashes
  • For posterior blepharitis: Include vertical eyelid massage to express meibomian gland secretions

Second-Line Treatment: Topical Antibiotics

• Antibiotic ointments: Apply to eyelid margins once or more daily for 5-7 days 2, 1

  • Bacitracin
  • Erythromycin

• Important considerations:

  • May need to rotate different antibiotics to prevent resistance 2
  • Treatment may need to be repeated intermittently based on symptom recurrence
  • Frequency and duration guided by severity and response to treatment

Third-Line Treatment: Advanced Options

• For moderate to severe cases:

  • Short-term topical corticosteroids for marked inflammation 1
  • Combination antibiotic/steroid topical treatments 1

• For Demodex-related blepharitis:

  • Lotilaner ophthalmic solution 0.25% (FDA-approved for Demodex blepharitis) 3, 4

• For persistent posterior blepharitis/MGD:

  • Oral antibiotics (anti-inflammatory properties): 2
    • Doxycycline, minocycline, or tetracycline daily, tapered after improvement
    • Oral erythromycin or azithromycin for women of childbearing age and children

Special Considerations

• Treatment duration: Blepharitis is typically chronic and requires long-term management 2, 1

  • Cleansing treatment may be required long-term as symptoms often recur when treatment is discontinued
  • Initial treatment should be reassessed after 2-4 weeks

• Contraindications and cautions: 2

  • Tetracyclines are contraindicated in pregnancy, nursing women, and children under 8 years
  • Tetracyclines can cause photosensitization, gastrointestinal upset, and rarely, azotemia
  • FDA warning: Oral azithromycin may lead to serious heart rhythm irregularities

• Procedural interventions: 1

  • Vectored thermal pulsation for meibomian gland dysfunction
  • Intralesional steroid injection or incision and curettage for persistent chalazia

Treatment Algorithm

1. Start with eyelid hygiene (warm compresses + cleansing) for all patients
2. If inadequate response after 2 weeks, add topical antibiotic ointment
3. If significant inflammation persists, consider short-term topical corticosteroids
4. For persistent posterior blepharitis/MGD, consider oral antibiotics (tetracyclines or macrolides)
5. For confirmed Demodex blepharitis, consider lotilaner ophthalmic solution

Prevention of Recurrence

• Continue regular eyelid hygiene even after symptoms improve
• Remove eye makeup completely daily
• Treat underlying conditions (rosacea, seborrheic dermatitis)
• Consider replacing contact lenses and case after resolution if applicable

Remember that blepharitis is often a chronic condition requiring ongoing management, and patient education about the long-term nature of the condition is essential for successful treatment.