What is the best treatment approach for a 17-year-old with chronic blepharitis since early childhood?

Treatment of Chronic Blepharitis in a 17-Year-Old

The best treatment approach for a 17-year-old with chronic blepharitis since early childhood begins with consistent eyelid hygiene using warm compresses and eyelid cleansing as the foundation of therapy, with additional treatments added based on response and specific type of blepharitis. 1, 2

First-Line Treatment

• Daily warm compresses should be applied to the eyelids for several minutes to soften crusts and warm meibomian secretions, using a clean washcloth with hot tap water, over-the-counter heat pack, or homemade bean/rice bag heated in the microwave 1
• Eyelid cleansing should be performed once or twice daily by gently rubbing the base of the eyelashes using either diluted baby shampoo or commercially available eyelid cleaner on a cotton swab, pad, or clean fingertip 1
• For posterior blepharitis/MGD, vertical eyelid massage can help express meibomian secretions 1
• Artificial tears can be used to manage associated dry eye symptoms 2

Second-Line Treatment

• If inadequate response to eyelid hygiene after 2-4 weeks, add topical antibiotics 2
• Topical antibiotic ointment such as bacitracin or erythromycin can be applied to the eyelid margins one or more times daily or at bedtime for a few weeks 1, 3
• For application of bacitracin, all scales and crusts should be carefully removed and the ointment then spread uniformly over the lid margins 3
• Hypochlorous acid 0.01% eye cleaners have strong antimicrobial effects for both anterior and posterior blepharitis 1

For Persistent or Severe Cases

• For a 17-year-old with persistent symptoms, oral erythromycin may be considered as tetracyclines are contraindicated in patients under 8 years of age due to dental enamel concerns 4
• Topical perfluorohexyloctane (FDA approved in 2023) can prevent tear evaporation and improve symptoms in patients with associated dry eye disease 1
• For cases with confirmed Demodex infestation (identified by collarettes at the base of eyelashes), lotilaner ophthalmic solution 0.25% is now available as the first approved therapy specifically for Demodex blepharitis 5
• In-office procedural treatments such as vectored thermal pulsation or microblepharoexfoliation may be considered for recalcitrant cases 1

Important Considerations

• The patient must understand that complete cure is usually not possible, and long-term management is required as symptoms often recur when treatment is discontinued 1, 6
• Topical antibiotic treatment should be used intermittently with different medications to prevent development of resistant organisms 1, 2
• Frequency and duration of treatment should be guided by the severity of the blepharitis and response to treatment 1
• For this adolescent patient with chronic disease since childhood, consistent adherence to daily eyelid hygiene is essential for long-term control 2, 7
• Caution the patient to avoid compresses that are too hot to prevent skin burns 1

Treatment Algorithm

1. Start with daily warm compresses and eyelid cleansing for 4 weeks 1, 2
2. If inadequate response, add topical antibiotic ointment (bacitracin or erythromycin) 1, 3
3. For persistent symptoms, consider oral erythromycin 4
4. If Demodex infestation is identified, consider lotilaner ophthalmic solution 0.25% 5
5. For associated dry eye symptoms, add artificial tears 2
6. For severe cases with inflammation, consider short-term topical anti-inflammatory agents 1, 7