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 additional therapies based on severity and type. 1

Treatment Algorithm

First-line Treatment

• Warm compresses: Apply for 10-15 minutes, 3-4 times daily
• Eyelid hygiene: Carefully remove all scales and crusts
• Gentle lid massage: To express meibomian glands in posterior blepharitis

Second-line Treatment

• Add topical antibiotics for signs of infection or risk of secondary infection:
  • Bacitracin ophthalmic ointment: Apply directly to the conjunctival sac 1-3 times daily, spreading uniformly over lid margins 1, 2
  • Erythromycin ointment may also be used

Third-line Treatment

• Consider combination antibiotic/steroid topical treatment for moderate to severe cases with significant inflammation 1
• Site-specific corticosteroids like loteprednol etabonate are preferred to minimize adverse effects 1

Fourth-line Treatment

• For persistent (>2 months) or large chalazia:
  • Consider intralesional steroid injection
  • Consider incision and curettage 1

Type-Specific Treatments

Anterior Blepharitis (Staphylococcal/Seborrheic)

• Focus on lid hygiene and topical antibiotics
• For seborrheic component: Treat underlying seborrheic dermatitis

Posterior Blepharitis (Meibomian Gland Dysfunction)

• Warm compresses and lid massage are particularly important
• For adults (non-pregnant, non-nursing) and children >8 years:
  • Consider oral tetracyclines (doxycycline or minocycline) 1
  • Alternative: Oral azithromycin (500 mg daily for 3 days in three cycles with 7-day intervals) 1
    • Caution: FDA warning about potential cardiac risk

Demodex Blepharitis

• Consider topical ivermectin for suspected Demodex mite infestation 1
• Tea tree oil-based lid scrubs may be beneficial 1
• Lotilaner ophthalmic solution 0.25% has shown efficacy in recent studies 3, 4

Management of Underlying Conditions

• Treat associated conditions that can exacerbate blepharitis:
  • Rosacea: Consider metronidazole or ivermectin 1
  • Seborrheic dermatitis: Appropriate dermatological treatment 1
  • Dry eye disease: Often coexists and requires concurrent management 4

Prevention of Recurrence

• Maintain good personal hygiene, including regular handwashing 1
• Remove eye makeup completely before bed 1
• Discontinue contact lens wear until symptoms resolve 1
• For recurrent cases, consider:
  • Decolonization strategies (nasal mupirocin, topical chlorhexidine, dilute bleach baths) 1
  • Long-term maintenance lid hygiene 5

When to Refer to an Ophthalmologist

Refer patients with:

• Visual changes
• Severe eyelid swelling
• Persistent symptoms despite treatment (>2-4 weeks)
• Suspected malignancy (particularly sebaceous carcinoma, which can mimic chronic blepharitis)
• Styes that develop into chalazia
• Suspected MRSA infections
• Immunocompromised status 1

Important Considerations

• Blepharitis is often chronic and requires long-term management 5, 6
• Reassess initial treatment after 2-4 weeks 1
• Patients should be instructed to avoid gross contamination of antibiotic ointments when applying directly to the eye 2
• Early diagnosis of sebaceous carcinoma or other malignancies significantly improves outcomes 1