What is the recommended treatment for blepharitis?

Blepharitis Treatment

The recommended first-line treatment for blepharitis is warm compresses (10-15 minutes, 3-4 times daily) combined with eyelid hygiene and gentle massage. 1

Step-wise Treatment Approach

The American Academy of Ophthalmology recommends a progressive treatment algorithm:

1. First-line therapy:

   • Warm compresses (10-15 minutes, 3-4 times daily)
   • Eyelid hygiene with dedicated cleansers
   • Gentle eyelid massage

2. Second-line therapy:

   • Continue first-line measures
   • Add topical antibiotic (bacitracin or erythromycin ointment) when signs of infection are present
   • Topical erythromycin can be applied as 1 cm strip to affected eye(s) up to six times daily 1

3. Third-line therapy:

   • Consider combination antibiotic/steroid topical treatment for moderate to severe cases
   • Requires careful monitoring for increased intraocular pressure and cataract formation 1

4. Fourth-line therapy (for persistent chalazia):

   • Consider intralesional steroid injection
   • Incision and curettage for persistent (>2 months) or large chalazia 1

Treatment Based on Blepharitis Type

Anterior Blepharitis (affecting eyelashes/skin)

• Typically staphylococcal and/or seborrheic in nature
• Focus on eyelid hygiene with warm compresses, eyelid scrubs, and over-the-counter eyelid cleansers 2
• Topical antibiotics for bacterial component

Posterior Blepharitis/Meibomian Gland Dysfunction (MGD)

• Warm compresses or in-office thermal pulsation treatments to clear meibomian gland obstructions 2
• Evidence shows topical azithromycin 1% solution combined with warm compresses is significantly more effective than warm compresses alone for posterior blepharitis 3
• Consider oral antibiotics for moderate-severe cases

Oral Antibiotic Options

For severe or unresponsive cases:

• Oral doxycycline (not recommended for children under 8 years) 1
• Oral erythromycin: pediatric dosing 30-40 mg/kg divided over 3 doses for 3 weeks, then twice daily for 4-6 weeks 1
• Oral azithromycin: 5 mg/kg daily for 2 months (use with caution due to potential cardiac risks) 1

Prevention and Patient Education

Key preventive measures:

• Maintain good eyelid hygiene consistently
• Complete removal of eye makeup before sleeping
• Consider dietary modifications (Mediterranean diet may help) 1
• Discontinue contact lens wear until symptoms resolve
• Treat underlying conditions (seborrheic dermatitis, rosacea, eczema, thyroid dysfunction) 1

When to Refer to a Specialist

Referral is recommended for:

• Visual changes or corneal involvement
• Severe eyelid swelling unresponsive to initial treatment
• Suspected malignancy
• Cicatricial changes in the conjunctiva
• Marked asymmetry between eyes
• Resistance to standard therapy
• Unifocal recurrent chalazia
• Loss of normal eyelid margin anatomy
• Focal lash loss (madarosis) 1

Follow-up

Patients should be reassessed after 2-4 weeks to evaluate treatment response, with education about the potentially chronic nature of blepharitis 1.