Treatment of Blepharitis
The cornerstone treatment for blepharitis is daily eyelid hygiene with warm compresses and lid scrubs, combined with artificial tears for symptomatic relief, especially when dry eye is present. 1 This approach should be maintained long-term as blepharitis is a chronic condition with no definitive cure.
First-Line Treatment Approach
Eyelid Hygiene
- Apply warm compresses to the eyelids for 5-10 minutes daily
- Follow with gentle lid scrubs using diluted baby shampoo or commercial eyelid cleansers
- For Demodex blepharitis: Use tea tree oil (50%) eyelid scrubs weekly and daily tea-tree-oil shampoo scrubs for at least 6 weeks 1
Symptomatic Relief
- Artificial tears for associated dry eye symptoms 1
- Continue eyelid hygiene indefinitely, as symptoms will recur when treatment is discontinued
Second-Line Treatments
Topical Medications
If symptoms persist after 2-4 weeks of eyelid hygiene:
- Topical antibiotics: Bacitracin or erythromycin ointment applied to eyelid margins once or twice daily for 1-2 weeks 1
- Antibiotic-steroid combinations: Loteprednol etabonate 0.5%/tobramycin 0.3% suspension for short-term treatment 1
- Topical corticosteroids: Brief course for significant inflammation, with careful monitoring for increased intraocular pressure and cataract formation 1
Oral Antibiotics
For moderate to severe cases, particularly posterior blepharitis:
- First-line oral antibiotic: Doxycycline due to its antimicrobial and anti-inflammatory properties 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) 1
- Erythromycin for children and pregnant women (pediatric dosing: 30-40 mg/kg divided over 3 doses for 3 weeks, then twice daily for 4-6 weeks) 1, 2
Treatment Based on Blepharitis Type
Anterior Blepharitis (affecting skin and lashes)
- Primarily staphylococcal and/or seborrheic
- Focus on eyelid hygiene and topical antibiotics
Posterior Blepharitis/Meibomian Gland Dysfunction
- Requires more aggressive warm compress therapy to clear meibomian gland obstruction 3
- Consider oral antibiotics (doxycycline, minocycline, tetracycline, or azithromycin) 1
Special Considerations
Contraindications
- Tetracyclines (doxycycline, minocycline) are contraindicated in pregnancy, nursing women, and children under 8 years 1
- Use erythromycin as an alternative for these populations 1, 2
Monitoring
- Regular IOP monitoring for patients on topical steroids (elevated IOP in ~3.7% of patients) 1
- Monitor for cardiovascular risks with oral azithromycin, especially in high-risk patients 1
- Watch for rare but serious concerns with doxycycline, including pseudotumor cerebri and drug interactions 1
Patient Education
- Emphasize the chronic nature of blepharitis requiring consistent long-term management
- Treatment can be intermittently adjusted based on symptom severity
- Regular follow-up is necessary to assess response and monitor for side effects
Emerging Treatments
- Antiparasitic medications (metronidazole, ivermectin, lotilaner) for Demodex blepharitis 1
- Thermal pulsation treatments for meibomian gland dysfunction 3
Remember that blepharitis management requires patience and consistency, as the condition tends to be chronic with periods of exacerbation and remission.