What is the treatment for blepharitis and arthritis?

Treatment of Blepharitis

Begin with daily eyelid hygiene using warm compresses and eyelid cleansing as the foundation of treatment, then escalate to topical antibiotics if symptoms persist after 2-4 weeks, reserving oral antibiotics for severe posterior blepharitis or meibomian gland dysfunction that fails conservative management. 1, 2

First-Line Treatment: Eyelid Hygiene

All patients with blepharitis should start with a structured eyelid hygiene regimen that includes:

• Warm compresses applied once or twice daily for several minutes to soften crusts and warm meibomian gland secretions 1, 2
• Eyelid cleansing performed daily using diluted baby shampoo or commercially available eyelid cleaners applied to the base of eyelashes with a cotton swab, pad, or clean fingertip 1, 2
• Hypochlorous acid 0.01% eye cleaners provide strong antimicrobial effects for both anterior and posterior blepharitis 2
• Meibomian gland expression through gentle vertical eyelid massage, particularly helpful for posterior blepharitis/MGD 1, 2

This regimen must be continued long-term, as symptoms typically recur when treatment is discontinued. 1, 2

Important Cautions for Lid Hygiene

• Patients with advanced glaucoma should avoid aggressive lid pressure, as this may increase intraocular pressure 1
• Patients with neurotrophic corneas require careful counseling to avoid corneal epithelial injury 1
• Ensure patients have adequate manual dexterity and judgment to perform these tasks safely 1
• Avoid compresses that are too hot to prevent skin burns 2

Second-Line Treatment: Topical Antibiotics

If eyelid hygiene alone provides inadequate relief after 2-4 weeks, add topical antibiotic ointment to the treatment regimen:

• Bacitracin or erythromycin ointment applied to eyelid margins one or more times daily or at bedtime for a few weeks 1, 2
• Azithromycin in sustained release formulation has shown efficacy in reducing signs and symptoms 1, 2
• Tobramycin/dexamethasone combination provides both antimicrobial and anti-inflammatory effects, but should be limited to 1-2 weeks to minimize steroid-related complications 3

Rotate different antibiotics intermittently to prevent development of resistant organisms. 1, 2

Third-Line Treatment: Oral Antibiotics

For posterior blepharitis/MGD with chronic symptoms not adequately controlled by topical treatments, prescribe oral antibiotics:

For Adults

• Doxycycline is the standard regimen, given daily and tapered after clinical improvement 1, 2
• Minocycline or tetracycline are alternatives 1
• Azithromycin 1 g per week for 3 weeks can be effective, though it carries risk of cardiac rhythm irregularities in high-risk patients 2
• Cephalexin 250-500 mg orally 4 times daily for 7-14 days addresses deeper or systemic infection, particularly when Staphylococcal infection is suspected 3

Tetracyclines work by decreasing lipase production in S. epidermidis and S. aureus, and also provide anti-inflammatory activity. 1

For Children, Pregnant Women, and Women of Childbearing Age

• Oral erythromycin 30-40 mg/kg divided over 3 doses for 3 weeks, then twice daily for 4-6 weeks 4
• Azithromycin 5 mg/kg daily for 2 months has shown clinical improvement 4
• Never use tetracyclines in children under 8 years (risk of dental staining), pregnant women, or nursing mothers 1, 4

Tetracycline Precautions

• Can cause photosensitization, gastrointestinal upset, vaginitis, and rarely azotemia 1
• May decrease effectiveness of oral contraceptives and potentiate warfarin effect 1
• Implicated in pseudotumor cerebri cases 1
• Consider sustained-release doxycycline preparations to reduce side effects 1

Adjunctive Treatments

For Inflammation

• Short course (1-2 weeks) of topical corticosteroids for severe eyelid or ocular surface inflammation, including marginal keratitis or phlyctenules 2
• Loteprednol etabonate or fluorometholone phosphate are safer steroid options due to limited ocular penetration 2
• Monitor intraocular pressure closely in patients with advanced glaucoma 3

For Associated Dry Eye

• Artificial tears, especially those containing oil or lipid products 2
• Topical cyclosporine may help with coexisting aqueous tear deficiency 2
• Perfluorohexyloctane prevents tear evaporation 2

For Refractory Cases

• Omega-3 fatty acid supplements have mixed evidence but may improve tear break-up time and meibum score 2
• Tea tree oil at 50% concentration for Demodex infestation in patients not improving with previous treatments 2
• In-office procedures such as vectored thermal pulsation or microblepharoexfoliation for recalcitrant cases 2

Treatment Algorithm Summary

1. Start all patients with daily warm compresses and eyelid cleansing 1, 2
2. After 2-4 weeks without adequate response, add topical antibiotic ointment (bacitracin or erythromycin) 2
3. For persistent posterior blepharitis/MGD, add oral doxycycline (adults) or erythromycin (children/pregnant women) 1, 4
4. For severe inflammation, consider short-course topical corticosteroids 2
5. Taper and discontinue treatments intermittently based on clinical response, but maintain long-term eyelid hygiene 1, 2

Critical Patient Education Points

• Blepharitis is typically chronic and cannot be permanently cured; successful management depends on long-term compliance with eyelid hygiene 2, 4
• Symptoms often recur when treatment is discontinued 1, 2
• Complete cure is usually not possible; the goal is symptom control 2

Evidence Quality Note

A Cochrane systematic review found uncertainty regarding the effectiveness of both topical and systemic treatments due to lack of high-quality evidence, though topical antibiotics showed some symptomatic relief and effectiveness in eradicating bacteria for anterior blepharitis. 5 Despite this limitation, the American Academy of Ophthalmology guidelines provide a structured approach based on clinical consensus and available evidence. 1, 3, 2