What is the treatment for blepharitis?

Treatment of Blepharitis

Begin with warm compresses and eyelid hygiene as first-line therapy for all types of blepharitis, escalating to topical antibiotics only after 2-4 weeks of inadequate response. 1

Understanding the Condition

Blepharitis divides into two anatomical types that guide treatment selection:

• Anterior blepharitis affects the eyelid skin, base of eyelashes, and follicles 1
• Posterior blepharitis (Meibomian Gland Dysfunction/MGD) affects the meibomian glands 1
• This is a chronic condition requiring ongoing management rather than expecting complete cure 1

First-Line Treatment (Start Here for All Patients)

Warm compresses and eyelid cleansing form the foundation of treatment:

• Apply warm compresses daily to soften crusts and warm meibomian secretions 1
• Perform eyelid cleansing once or twice daily using diluted baby shampoo or commercially available eyelid cleaners 1
• For posterior blepharitis/MGD specifically, add vertical eyelid massage to express meibomian secretions 1
• Hypochlorous acid 0.01% eye cleaners provide strong antimicrobial effects for both anterior and posterior blepharitis 1
• Add artificial tears to manage associated dry eye symptoms 1
• Caution: Ensure compresses are not too hot to prevent skin burns 1

Continue this regimen for 2-4 weeks before escalating therapy. 1

Second-Line Treatment (After 2-4 Weeks of Inadequate Response)

Add topical antibiotic ointment when first-line measures fail:

• Bacitracin or erythromycin ointment applied to eyelid margins one or more times daily for a few weeks 1
• For bacitracin specifically: remove all scales and crusts first, then spread ointment uniformly over lid margins 1-3 times daily 2
• Consider antibiotics earlier when signs of bacterial infection are present 1
• Azithromycin has shown efficacy in reducing signs and symptoms 1

Important antibiotic considerations:

• Use topical antibiotics intermittently with different medications to prevent resistant organisms 1
• Long-term antibiotic use may lead to resistant organisms 1
• Topical antibiotics reduce bacterial load and provide symptomatic relief for anterior blepharitis 3

Third-Line Treatment (Severe or Resistant Cases)

For cases not responding to topical therapy:

• Oral antibiotics: tetracyclines for adults or erythromycin for children and pregnant women 1
• Topical perfluorohexyloctane can prevent tear evaporation and improve symptoms in patients with associated dry eye disease 1
• In-office procedures: vectored thermal pulsation or microblepharoexfoliation for recalcitrant cases 1

Special Situations

Preparing for intraocular surgery:

• Consider antibiotics like ofloxacin to reduce the risk of endophthalmitis 1
• Ofloxacin is not first-line for routine blepharitis and should be reserved for confirmed bacterial infection or surgical preparation 1

Progression to preseptal cellulitis:

• Immediately initiate oral amoxicillin-clavulanate (5-10 days) or cephalexin (7-14 days) to cover Staphylococcus aureus and Streptococcus species 4
• Add topical antibiotic-steroid combination (e.g., tobramycin/dexamethasone) to eyelid margins for 1-2 weeks maximum 4
• Do not treat preseptal cellulitis with topical antibiotics alone—systemic therapy is required 4

Long-Term Management

Set realistic expectations with patients:

• Daily eyelid hygiene is essential for long-term control 1
• Symptoms often recur when treatment is discontinued 1
• Frequency and duration of treatment should be guided by severity and response 1

Common Pitfalls to Avoid

• Do not prescribe antibiotics as first-line therapy without trying eyelid hygiene measures first 1
• Do not use topical antibiotics continuously long-term due to resistance concerns 1
• Do not start corticosteroid drops before ruling out infectious keratitis, as steroids can worsen certain infections 4
• Do not expect complete cure—this is a chronic condition requiring ongoing management 1