What is the treatment for blepharitis?

Treatment of Blepharitis

First-Line Treatment: Eyelid Hygiene

Begin with warm compresses applied for 5-10 minutes, 3-4 times daily, combined with daily eyelid cleansing using diluted baby shampoo or commercially available eyelid cleaners—this is the fundamental treatment for all types of blepharitis. 1

• Apply warm compresses to soften crusts and warm meibomian secretions, promoting drainage 1
• Clean the eyelid margin once or twice daily using diluted baby shampoo or commercial eyelid cleaner on a cotton ball, cotton swab, or clean fingertip to remove debris and inflammatory material 1
• For posterior blepharitis/meibomian gland dysfunction (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, especially those containing oil or lipid products, can help manage associated dry eye symptoms 1

Critical caveat: Patients must understand that blepharitis is typically chronic and cannot be permanently cured—daily eyelid hygiene is essential for long-term control and symptoms often recur when treatment is discontinued. 1

Second-Line Treatment: Topical Antibiotics (After 2-4 Weeks Without Improvement)

If eyelid hygiene provides inadequate relief after 2-4 weeks, add topical antibiotic ointment such as bacitracin or erythromycin to the eyelid margins one or more times daily for a few weeks. 1

• Bacitracin ointment should be applied directly into the conjunctival sac 1 to 3 times daily; in blepharitis, all scales and crusts should be carefully removed and the ointment then spread uniformly over the lid margins 2
• Erythromycin ointment is an alternative first-line antibiotic option 1
• Topical antibiotics are effective in eradicating bacteria from the eyelid margin and providing symptomatic relief for anterior blepharitis 3
• Important warning: Topical antibiotic treatment should be used intermittently with different medications to prevent development of resistant organisms—long-term continuous use may lead to resistant organisms. 1

Third-Line Treatment: Oral Antibiotics for Severe or Resistant Cases

For severe or resistant cases not adequately controlled by eyelid cleansing or topical treatments, consider oral antibiotics such as doxycycline, minocycline, or tetracycline. 1

• Doxycycline is a standard regimen for severe cases of blepharitis 1
• Azithromycin oral pulse regimen: 1 g per week for 3 weeks can be effective 1
• Contraindication: Tetracyclines are contraindicated in pregnancy and children under 8 years old 1
• For women of childbearing age and children, use erythromycin or azithromycin as alternatives 1
• Azithromycin warning: May cause abnormalities in heart electrical activity with potential for serious cardiac rhythm irregularities, especially in patients with high baseline cardiovascular risk 1

Adjunctive Treatments for Specific Situations

Topical Corticosteroids

• Consider a short course of topical corticosteroids for eyelid or ocular surface inflammation, including marginal keratitis or phlyctenules 1
• Loteprednol etabonate and fluorometholone phosphate are safer options due to their site-specific action and limited ocular penetration 1
• Use with caution and under ophthalmological supervision, particularly in patients with advanced glaucoma where intraocular pressure monitoring is essential 1

Additional Options

• Cyclosporine topical may be useful in some patients with posterior blepharitis and can also help manage coexisting aqueous tear deficiency 1
• Omega-3 fatty acid supplements have mixed evidence, with some studies showing improvement in tear break-up time, dry eye symptoms, and meibum score 1
• Topical perfluorohexyloctane can prevent tear evaporation and improve symptoms in patients with associated dry eye disease 1
• Tea tree oil at 50% concentration can be considered for treatment of Demodex in patients who do not improve with previous treatments 1

In-Office Procedural Treatments

For recalcitrant cases that fail medical management, consider in-office procedural treatments such as vectored thermal pulsation or microblepharoexfoliation. 1

Important Safety Considerations

• 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 1
• Patients with neurotrophic corneas require proper counseling to avoid injury to corneal epithelium during eyelid cleaning 1
• Frequency and duration of treatment should be guided by the severity of the blepharitis and response to treatment 1