What is the treatment for blepharitis?

Treatment of Blepharitis

Begin with daily warm compresses for 5-10 minutes and eyelid hygiene using diluted baby shampoo or hypochlorous acid 0.01% cleaners, which form the foundation of blepharitis management regardless of type. 1

Understanding the Disease Classification

Blepharitis divides into two main categories 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
• Both types are typically chronic conditions requiring ongoing management rather than expecting complete cure 1

First-Line Treatment Algorithm

Initial Management (Weeks 1-4)

Start all patients on this regimen before escalating therapy:

• Apply warm compresses to eyelids for 5-10 minutes once or twice daily to soften crusts and warm meibomian secretions 1, 2
• Perform eyelid cleansing once or twice daily using diluted baby shampoo or commercially available eyelid cleaners 1
• Use hypochlorous acid 0.01% eye cleaners for strong antimicrobial effects in both anterior and posterior blepharitis 1
• For posterior blepharitis/MGD, add vertical eyelid massage after warm compresses to express meibomian secretions 1
• Prescribe artificial tears, especially oil or lipid-containing products, to manage associated dry eye symptoms 1

Critical safety consideration: Counsel patients to avoid compresses that are too hot to prevent skin burns 1. Patients with advanced glaucoma should avoid aggressive lid pressure during massage 2, and those with neurotrophic corneas require careful counseling to avoid corneal epithelial injury during cleansing 2.

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

Topical Antibiotic Therapy

Add topical antibiotic ointment when first-line measures provide inadequate relief or when signs of bacterial infection are present:

• Apply bacitracin or erythromycin ointment to eyelid margins one or more times daily for a few weeks 1
• Azithromycin topical has shown efficacy in reducing signs and symptoms 1
• Use antibiotics intermittently with different medications to prevent development of resistant organisms 1
• Reserve ofloxacin for cases with confirmed bacterial infection or when preparing for intraocular surgery to reduce endophthalmitis risk 1

Important caveat: Long-term antibiotic use may lead to resistant organisms, so avoid continuous prolonged therapy 1.

Third-Line Treatment for Severe or Resistant Cases

Systemic Antibiotic Therapy

For moderate to severe cases not responding to topical therapy, escalate to oral antibiotics:

• Adults: Doxycycline is the standard regimen for severe cases 1, 2
• Alternative for adults: Azithromycin oral pulse regimen of 1 g per week for 3 weeks 1
• Children and pregnant women: Erythromycin (tetracyclines are contraindicated in pregnancy, nursing women, and children under 8 years) 1, 2

Cardiac warning: Azithromycin may cause abnormalities in heart electrical activity with potential for serious cardiac rhythm irregularities, especially in patients with high baseline cardiovascular risk 1.

Anti-Inflammatory Therapy

For marked eyelid or ocular surface inflammation, including marginal keratitis or phlyctenules:

• Use a short course of topical corticosteroids 1
• Prefer loteprednol etabonate or fluorometholone phosphate due to their site-specific action and limited ocular penetration 1
• Consider cyclosporine topical for posterior blepharitis with coexisting aqueous tear deficiency 1

Special Considerations and Advanced Therapies

Demodex Blepharitis

When collarettes are present at the base of eyelashes (pathognomonic for Demodex):

• Consider tea tree oil at 50% concentration for patients who do not improve with previous treatments 1
• Lotilaner ophthalmic solution 0.25% is the first FDA-approved therapy that eradicates Demodex mites in one-half to two-thirds of patients 3, 4

Adjunctive Therapies

• Topical perfluorohexyloctane can prevent tear evaporation and improve symptoms in patients with associated dry eye disease 1
• Omega-3 fatty acid supplements have mixed evidence but may improve tear break-up time, dry eye symptoms, and meibum score 1
• In-office procedural treatments such as vectored thermal pulsation or microblepharoexfoliation may be considered for recalcitrant cases 1

Atopic Eyelid Dermatitis Component

If atopic dermatitis is contributing:

• Apply tacrolimus 0.1% ointment once daily to external eyelids and lid margins for 2-4 weeks 2
• For children aged 2-17 years, use tacrolimus 0.03% ointment, with option to increase to 0.1% if needed under ophthalmology guidance 2

Essential Patient Education Points

Patients must understand these critical concepts for successful management:

• Blepharitis is typically chronic and cannot be permanently cured 1
• Symptoms often recur when treatment is discontinued, requiring long-term management 1
• Daily eyelid hygiene is essential for long-term control 1
• Successful management depends on long-term treatment regimen compliance 1
• Frequency and duration of treatment should be guided by severity and response 1