What is the treatment for blepharitis?

Treatment for Blepharitis

The first-line treatment for blepharitis is warm compresses for 10-15 minutes 3-4 times daily, combined with eyelid hygiene and gentle massage, as recommended by the American Academy of Ophthalmology. 1

Treatment Algorithm

First-Line Treatment

• Warm compresses: Apply for 10-15 minutes, 3-4 times daily
• Eyelid hygiene: Clean eyelid margins with commercial lid cleansers or diluted baby shampoo
• Gentle massage: To express meibomian glands after warm compresses

Second-Line Treatment

• Add topical antibiotics (bacitracin or erythromycin ointment) when:
  • Signs of bacterial infection are present
  • Risk of secondary infection exists
  • First-line treatment shows inadequate response after 2-4 weeks

Third-Line Treatment

• Combination antibiotic/steroid topical treatments for moderate to severe cases
• Topical loteprednol etabonate/tobramycin has shown efficacy with less risk of intraocular pressure rise compared to dexamethasone combinations 1

Fourth-Line Treatment

• For persistent (>2 months) or large chalazia:
  • Intralesional steroid injection
  • Incision and curettage

Type-Specific Treatments

Anterior Blepharitis (affecting skin and lashes)

• Usually staphylococcal and/or seborrheic in nature
• Focus on eyelid hygiene and topical antibiotics
• For children: topical erythromycin or bacitracin ointment 1

Posterior Blepharitis/Meibomian Gland Dysfunction (MGD)

• Heat therapy is critical to melt thickened meibum
• Consider in-office thermal pulsation treatment for obstruction clearance 2
• For cases not controlled by eyelid hygiene, consider oral antibiotics:
  • Macrolides (erythromycin, azithromycin) have both antimicrobial and anti-inflammatory properties 1
  • For children: oral erythromycin (30-40 mg/kg divided over 3 doses for 3 weeks, then twice daily for 4-6 weeks) or azithromycin (5 mg/kg daily for 2 months for children under 8 years) 1

Important Considerations

Pediatric Patients

• Tetracyclines (doxycycline, minocycline) are contraindicated in children under 8 years due to risk of dental enamel staining 1
• Macrolides are preferred for systemic treatment in children

Adjunctive Measures

• Environmental modifications:
  • Avoid excess dryness, wind, and air-conditioned environments
  • Increase blinking frequency (>10 times/minute) when using computers or watching TV 1
• Dietary modifications: Mediterranean diet may be beneficial 1

Prevention of Recurrence

• Complete removal of eye makeup
• Treatment of underlying conditions
• Discontinue contact lens wear until symptoms resolve
• For recurrent styes:
  • Nasal decolonization with mupirocin twice daily for 5-10 days
  • Topical body decolonization with chlorhexidine antiseptic solution for 5-14 days or dilute bleach baths 1

When to Refer

Refer to a specialist when:

• Visual changes occur
• Corneal involvement is present
• Severe eyelid swelling is unresponsive to initial treatment
• Malignancy is suspected
• Cicatricial changes in the conjunctiva develop 1

When to Consider Biopsy

• Marked asymmetry between eyes
• Resistance to standard therapy
• Unifocal recurrent chalazia
• Loss of normal eyelid margin anatomy
• Focal lash loss (madarosis) 1

Remember that blepharitis is often a chronic condition requiring long-term management. Patients should be educated about the potentially chronic nature of the condition and reassessed after 2-4 weeks to evaluate treatment response 1, 3.