What is the treatment for blepharitis?

Blepharitis Treatment

The treatment of blepharitis should follow a stepwise approach, beginning with warm compresses and eyelid hygiene, followed by topical antibiotics such as erythromycin or bacitracin for signs of infection, with oral antibiotics reserved for moderate to severe cases that don't respond to initial therapy. 1

First-Line Treatment

1. Eyelid Hygiene and Warm Compresses
   • Apply warm compresses for 10-15 minutes, 3-4 times daily 1
   • Follow with gentle eyelid cleansing to remove scales and crusts 1, 2
   • For anterior blepharitis, focus on cleaning the eyelashes and lid margins
   • For posterior blepharitis/meibomian gland dysfunction (MGD), include gentle massage of eyelids to express meibomian glands 3

Second-Line Treatment

1. Topical Antibiotics
   • Add when there are signs of infection or risk of secondary infection 1
   • Options include:
     • Bacitracin ophthalmic ointment: Apply directly to the conjunctival sac 1-3 times daily; for blepharitis, carefully remove all scales and crusts and spread uniformly over lid margins 2
     • Erythromycin ophthalmic ointment: Apply 1-4 times daily for 7-10 days for acute symptoms 1
   • Patients should avoid gross contamination when applying ointment 2

Third-Line Treatment

1. Combination Antibiotic/Steroid Treatment
   • Consider for moderate to severe cases 1
   • Topical corticosteroid preparations may help with marked inflammation 4
   • Use with caution due to potential side effects of steroids

Fourth-Line Treatment

1. Advanced Interventions for Persistent Cases
   • Consider intralesional steroid injection or incision and curettage for persistent (>2 months) or large chalazia 1
   • Oral antibiotics (e.g., tetracyclines) for moderate to severe cases not responding to topical therapy 1
     • Note: Tetracyclines are contraindicated in pregnancy, nursing women, and children under 8 years 1
     • Oral azithromycin may lead to serious heart rhythm irregularities 1

Special Considerations for Demodex Blepharitis

For Demodex blepharitis (identifiable by collarettes at the base of eyelashes):

• Lotilaner ophthalmic solution 0.25% is the first FDA-approved therapy specifically for Demodex blepharitis 5
• It has been shown to eradicate Demodex mites in 50-67% of patients with continued benefits through 1 year 5

Monitoring and Follow-up

• Evaluate for redness, swelling, crusting at lid margins, discharge, eyelash abnormalities, and meibomian gland expression 1
• Follow up in 2-4 weeks for moderate cases 1
• Consider referral to an ophthalmologist for:
  • Persistent styes (>2 weeks)
  • Styes that develop into chalazia
  • Suspected MRSA infections
  • Visual changes
  • Severe eyelid swelling
  • Immunocompromised patients 1

Prevention of Recurrence

• Regular eyelid hygiene is essential for preventing recurrences 1
• Complete removal of eye makeup
• Treatment of underlying conditions (rosacea, seborrheic dermatitis)
• Discontinue contact lens wear until symptoms resolve 1
• Rotate different antibiotics with different mechanisms of action if repeated courses are needed 1

Common Pitfalls to Avoid

1. Inadequate treatment application: Ensure proper application of medications and complete removal of scales/crusts before applying ointments 1, 2

2. Premature discontinuation: Blepharitis is often chronic and requires long-term management 4, 6

3. Overuse of antibiotics: Can lead to antibiotic resistance 1

4. Missing underlying causes: Consider associated conditions like dry eye, rosacea, or seborrheic dermatitis 4

5. Failure to consider malignancy: Sebaceous carcinoma should be considered in cases of chronic or atypical blepharitis 1

6. Neglecting pre-surgical management: Control of moderate to severe blepharitis is necessary prior to intraocular surgery to reduce the risk of postoperative endophthalmitis 1