What is the treatment for blepharitis?

Treatment of Blepharitis

The first-line treatment for blepharitis consists of daily warm compresses and eyelid cleansing, which should be maintained long-term as symptoms often recur when treatment is discontinued. 1

First-Line Treatment Approach

• Warm compresses should be applied to soften crusts and warm meibomian secretions, followed by gentle eyelid cleansing using diluted baby shampoo or commercially available eyelid cleaner on a pad, cotton ball, cotton swab, or clean fingertip 2
• For posterior blepharitis/Meibomian Gland Dysfunction (MGD), vertical eyelid massage helps express meibomian secretions 1
• Once or twice-daily compresses and massage is generally adequate, but may need to be continued indefinitely as blepharitis is typically chronic 2
• Hypochlorous acid 0.01% eye cleaners have strong antimicrobial effects for both anterior and posterior blepharitis 1
• Artificial tears can help manage associated dry eye symptoms 1

Second-Line Treatment: Topical Antibiotics

• If inadequate response to eyelid hygiene after 2-4 weeks, add topical antibiotic ointment such as bacitracin or erythromycin applied to eyelid margins once or more daily or at bedtime for a few weeks 2
• Topical antibiotics provide symptomatic relief and effectively decrease bacteria from the eyelid margin in anterior blepharitis 2
• Antibiotic treatment should be used intermittently with different medications to prevent development of resistant organisms 2
• The frequency and duration of treatment should be guided by the severity of blepharitis and response to treatment 2

For Persistent or Severe Cases

• For patients with MGD whose symptoms are not adequately controlled by eyelid cleansing or meibomian gland expression, oral tetracyclines and topical antibiotics may be helpful 2
• Doxycycline, minocycline, or tetracycline can be given daily and tapered after clinical improvement 2
• Oral erythromycin or azithromycin can be used for women of childbearing age and children (tetracyclines are contraindicated in pregnancy, nursing women, and children under 8 years) 2
• Tetracyclines and macrolide antibiotics also have anti-inflammatory activity 2
• In-office procedural treatments such as vectored thermal pulsation or microblepharoexfoliation may be considered for recalcitrant cases 1

Important Considerations and Cautions

• Blepharitis is typically chronic and requires ongoing management rather than expecting complete cure 1, 3
• Patients should be advised that warm compress and eyelid cleansing treatment may be required long-term 2
• Eyelid cleaning can be dangerous if the patient lacks manual dexterity or necessary skill to perform the task safely 2
• Frequent manipulation of the eyelid may lead to mechanically induced irritation 2
• Patients with advanced glaucoma should avoid aggressive lid pressure as it may increase eye pressure 2
• Tetracyclines can cause photosensitization, gastrointestinal upset, vaginitis, and rarely, azotemia 2
• Oral azithromycin has been associated with a small increase in cardiovascular deaths in patients with high baseline risk of cardiovascular disease 2

Treatment Algorithm

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

Blepharitis management requires patient education about the chronic nature of the condition and the importance of consistent, long-term eyelid hygiene to control symptoms and prevent recurrence 1, 5.