What is the treatment for blepharitis?

Blepharitis Treatment

The first-line treatment for blepharitis consists of daily warm compresses and eyelid cleansing, which should be continued long-term as the condition is typically chronic and requires ongoing management. 1

Classification of Blepharitis

• Blepharitis can be classified as anterior (affecting eyelid skin, base of eyelashes, and follicles) or posterior (affecting meibomian glands, also known as Meibomian Gland Dysfunction or MGD) 1

First-Line Treatment

• Apply warm compresses to the affected eyelid for 5-10 minutes, 3-4 times daily to soften crusts and warm meibomian secretions 1, 2
• Clean the eyelid margins once or twice daily using diluted baby shampoo or commercially available eyelid cleaner on a cotton ball, cotton swab, or clean fingertip 1
• For posterior blepharitis/MGD, perform gentle vertical eyelid massage to help express meibomian secretions 1
• Hypochlorous acid 0.01% eye cleaners have strong antimicrobial effects for both anterior and posterior blepharitis 1
• Artificial tears can be used to manage associated dry eye symptoms 1

Second-Line Treatment (If No Improvement After 2-4 Weeks)

• Add topical antibiotic ointment such as bacitracin or erythromycin to the eyelid margins one to three times daily for a few weeks 1, 3
• For bacitracin ophthalmic ointment, apply directly to the lid margins after carefully removing all scales and crusts 3
• Use different antibiotics intermittently to prevent development of resistant organisms 1

For Persistent or Severe Cases

• Consider oral antibiotics such as doxycycline, minocycline, or tetracycline for patients with meibomian gland dysfunction not adequately controlled by eyelid cleansing or topical treatments 1, 2
• For pregnant women or children under 8 years, use erythromycin or azithromycin instead of tetracyclines 1, 2
• Topical perfluorohexyloctane can prevent tear evaporation and improve symptoms in patients with associated dry eye disease 1
• In-office procedural treatments such as vectored thermal pulsation or microblepharoexfoliation may be considered for recalcitrant cases 1, 4

Important Considerations

• Complete cure is usually not possible; blepharitis is typically chronic and requires ongoing management 1, 5
• Symptoms often recur when treatment is discontinued, so patients should be advised that long-term management is necessary 1
• Avoid compresses that are too hot to prevent skin burns 1
• Avoid aggressive manipulation of the eyelid, particularly in patients with advanced glaucoma, as it may increase eye pressure 2
• Patients with neurotrophic corneas require proper counseling to avoid injury to corneal epithelium during eyelid cleaning 2

Treatment Algorithm

1. Start with warm compresses and eyelid hygiene for 2-4 weeks 1
2. If inadequate response, add topical antibiotic ointment (bacitracin or erythromycin) 1, 3
3. For severe or resistant cases, consider oral antibiotics (tetracyclines for adults, erythromycin for children and pregnant women) 1, 2
4. For recalcitrant cases, consider in-office procedures like thermal pulsation 1, 4

Common Pitfalls

• Expecting complete cure rather than focusing on long-term management 1, 6
• Discontinuing treatment once symptoms improve, leading to recurrence 1
• Overuse of antibiotics leading to resistant organisms 1
• Failure to identify and address underlying conditions such as seborrheic dermatitis, rosacea, or eczema that may contribute to blepharitis 7, 8