What is the treatment for blepharitis?

Treatment of Blepharitis

The first-line treatment for blepharitis consists of warm compresses (10-15 minutes, 3-4 times daily) combined with eyelid hygiene and gentle massage, with topical antibiotics such as bacitracin or erythromycin ointment added for signs of infection. 1

Types of Blepharitis and Diagnosis

Blepharitis can be classified into:

• Anterior blepharitis: Affects the anterior lid margin and eyelashes, typically staphylococcal and/or seborrheic in nature
• Posterior blepharitis: Involves meibomian gland dysfunction (MGD)
• Demodex blepharitis: Caused by Demodex mite infestation, identified by collarettes at the base of eyelashes (pathognomonic sign) 2

When evaluating patients, look for:

• Redness and swelling of eyelid margins
• Crusting at lid margins
• Discharge
• Eyelash abnormalities
• Meibomian gland expression
• Associated conditions (dry eye, rosacea) 1

Treatment Algorithm

First-line Treatment

• Warm compresses (10-15 minutes, 3-4 times daily)
• Eyelid hygiene with gentle massage
• For blepharitis, all scales and crusts should be carefully removed before applying treatment 1, 3

Second-line Treatment

• Add topical antibiotics for signs of infection or risk of secondary infection:
  • Bacitracin ointment applied directly to lid margins 1-3 times daily 3
  • Erythromycin ointment 1-4 times daily for 7-10 days for acute symptoms 1

Third-line Treatment

• Consider combination antibiotic/steroid topical treatment for moderate to severe cases 1, 4
  • Fixed combinations address both infectious and inflammatory components
  • Short-term use only to avoid steroid-related complications

Fourth-line Treatment

• For persistent cases (>2 months) or large chalazia:
  • Consider intralesional steroid injection
  • Incision and curettage may be necessary 1

For Demodex Blepharitis

• Tea tree oil-based lid scrubs
• Metronidazole or ivermectin
• Lotilaner ophthalmic solution 0.25% (recently FDA-approved) has shown effectiveness in eradicating Demodex mites 2, 5

For Refractory Cases

• Advanced in-office procedures:
  • Intense pulsed light therapy
  • Vectored thermal pulsation
  • Microblepharoexfoliation 1

For Moderate to Severe Cases

• Oral antibiotics may be necessary:
  • Tetracyclines (doxycycline, minocycline)
  • Azithromycin
  • Contraindicated in pregnancy, nursing women, and children under 8 years 1

Prevention and Maintenance

• Maintain good personal hygiene, including regular handwashing
• Remove eye makeup completely
• Treat underlying conditions (rosacea, seborrheic dermatitis)
• Discontinue contact lens wear until symptoms resolve 1

When to Refer to an Ophthalmologist

Refer patients with:

• Persistent styes (>2 weeks)
• Styes that develop into chalazia
• Suspected MRSA infections
• Visual changes
• Severe eyelid swelling
• Immunocompromised status 1

Important Considerations and Pitfalls

• Chronic nature: Blepharitis is often chronic and requires long-term management 6
• Reassessment: Evaluate initial treatment after 2-4 weeks 1
• Malignancy warning signs: Unilateral persistent blepharitis, atypical eyelid inflammation, focal lash loss, and recurrent chalazia may indicate underlying malignancy, such as sebaceous carcinoma 1
• Decolonization strategies: For recurrent styes, consider nasal mupirocin, topical body decolonization with chlorhexidine, or dilute bleach baths 1

Remember that while symptoms may improve with treatment, complete cure is often not possible in many cases, and long-term management is typically required 4.