What is the treatment for blepharitis?

Treatment of Blepharitis

The most effective treatment approach for blepharitis is a combination of daily eyelid hygiene with warm compresses and eyelid cleansing as first-line therapy, with antibiotics reserved for cases with inadequate response or signs of infection. 1, 2

First-Line Treatment

• Apply warm compresses to the eyelids for several minutes to soften adherent material and warm meibomian secretions, using hot tap water on a clean washcloth, over-the-counter heat pack, or homemade bean/rice bag heated in the microwave 1
• Perform eyelid cleansing through brief, gentle massage of the eyelids using diluted baby shampoo or commercially available eyelid cleaner on a pad, cotton ball, cotton swab, or clean fingertip 1
• For anterior blepharitis, focus on cleansing the eyelid margins from side to side to remove crusting from the eyelashes 1, 2
• For posterior blepharitis/MGD, perform vertical eyelid massage to express meibomian secretions 1, 3
• Consider eye cleaners with hypochlorous acid at 0.01% which have strong antimicrobial effects for both anterior and posterior blepharitis 1
• Use artificial tears to manage associated dry eye symptoms 2
• Maintain once or twice-daily compresses and massage regimen at a time convenient for the patient 1

Second-Line Treatment

• For anterior blepharitis with inadequate response to hygiene measures, apply topical antibiotic ointment such as bacitracin or erythromycin to eyelid margins one or more times daily or at bedtime for a few weeks 1, 3
• Consider rotating different antibiotics to prevent resistance development 3
• For posterior blepharitis/MGD with persistent symptoms, consider oral antibiotics such as doxycycline, minocycline, or tetracycline 3
• For children or women of childbearing age, use erythromycin or azithromycin instead of tetracyclines 3
• Topical anti-inflammatory agents (e.g., corticosteroids) may be used for short durations (1-2 weeks) in cases with marked inflammation 1, 3

Advanced Treatment Options

• For severe cases, consider in-office procedural treatments such as vectored thermal pulsation or microblepharoexfoliation 1
• For cases with Demodex involvement, consider antiparasitic medications like metronidazole, ivermectin, or lotilaner 1
• Topical perfluorohexyloctane may be beneficial in some cases 1
• Topical cyclosporine can be considered for cases with significant inflammatory component 1

Important Considerations

• Inform patients that blepharitis is typically chronic and complete cure is usually not possible, but symptoms can be significantly improved with continual daily treatment 1, 2
• Caution patients with advanced glaucoma or history of glaucoma filtering procedure to avoid aggressive lid pressure during massage 1
• Counsel patients with neurotrophic corneas about potential risk of corneal epithelial injury during lid hygiene 1
• Be aware that long-term antibiotic treatment may result in development of resistant organisms 1, 2
• Consider addressing moderate to severe blepharitis prior to intraocular surgical procedures to reduce risk of postoperative endophthalmitis 1, 3
• Tailor the therapeutic plan according to the patient's manual dexterity and ability to safely perform eyelid hygiene 1

Treatment Algorithm

1. Begin with eyelid hygiene (warm compresses and cleansing) for 2-4 weeks 2
2. If inadequate response, add topical antibiotic (bacitracin or erythromycin ointment) 2, 3
3. For persistent symptoms, consider oral antibiotics or short-term topical corticosteroids 3
4. For severe or resistant cases, consider in-office procedures or specialized treatments 1