What is the treatment for acute blepharitis?

Treatment of Acute Blepharitis

The cornerstone treatment for acute blepharitis is daily eyelid hygiene with warm compresses and lid scrubs, supplemented with artificial tears for symptomatic relief. 1

First-Line Management

• Eyelid Hygiene (Primary Treatment):

  • Apply warm compresses to eyelids for 5-10 minutes
  • Follow with gentle lid scrubs using diluted baby shampoo or commercial lid cleansers
  • Perform this routine 1-2 times daily

• Artificial Tears:

  • Use preservative-free formulations when possible
  • Apply 4-6 times daily as needed for dry eye symptoms 1

Topical Treatments

• Topical Antibiotics (for bacterial involvement):

  • Bacitracin or erythromycin ointment applied to eyelid margins once or twice daily for 1-2 weeks if symptoms persist after 2-4 weeks of eyelid hygiene 1
  • Apply a small amount to the lid margin using a clean fingertip or cotton swab

• Topical Corticosteroids (for significant inflammation):

  • Brief course only, with careful monitoring
  • Site-specific options like loteprednol etabonate preferred
  • Monitor for increased intraocular pressure and cataract formation 1
  • Antibiotic-steroid combinations (e.g., loteprednol etabonate 0.5%/tobramycin 0.3%) may be used for short-term treatment 1

Oral Antibiotics (for moderate to severe cases)

For cases not responding to topical therapy or with significant inflammation:

• First-line oral option:

  • Doxycycline: Initial treatment followed by maintenance and tapering after improvement
  • Contraindicated in pregnancy, nursing women, and children under 8 years 1

• Alternative oral antibiotics:

  • Minocycline or tetracycline (similar efficacy to doxycycline)
  • Azithromycin for women of childbearing age and children (500 mg daily for 3 days in three cycles with 7-day intervals, or 1 g weekly for 3 weeks)
  • Erythromycin for children and women of childbearing age 1

Special Considerations

• For Demodex blepharitis:

  • Tea tree oil (50%) eyelid scrubs weekly
  • Daily tea-tree-oil shampoo scrubs for at least 6 weeks 1

• For posterior blepharitis/MGD:

  • More aggressive warm compresses
  • Gentle lid massage to express meibomian glands
  • Consider oral doxycycline for anti-inflammatory properties 2

Important Clinical Pearls

• Blepharitis is typically chronic with no definitive cure; consistent management is necessary for long-term symptom control 1, 3
• Treatment efficacy should be assessed after 2-4 weeks; adjust therapy if inadequate response
• Avoid long-term use of topical corticosteroids due to risk of glaucoma and cataracts 1
• Regular IOP monitoring is necessary for patients on topical steroids 1
• Patient education about the chronic nature of blepharitis and importance of consistent lid hygiene is crucial for successful management 1

Treatment Pitfalls to Avoid

• Discontinuing lid hygiene once symptoms improve (should be continued long-term)
• Overuse of topical antibiotics leading to resistance
• Prolonged steroid use without monitoring for complications
• Failing to identify and treat underlying conditions (rosacea, seborrheic dermatitis)
• Using tetracyclines in contraindicated populations (pregnancy, children under 8) 1