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, then add topical antibiotic ointment (bacitracin or erythromycin) to lid margins if inadequate response after 2-4 weeks. 1

Classification Matters for Treatment Selection

Blepharitis divides into two anatomic types that guide therapy:

• Anterior blepharitis affects the eyelid skin, lash base, and follicles 1
• Posterior blepharitis (Meibomian Gland Dysfunction/MGD) affects the meibomian glands 1

Both types often coexist and require similar foundational treatment with some specific modifications. 2

First-Line Treatment Algorithm

Step 1: Eyelid Hygiene (All Patients, Indefinitely)

• Warm compresses applied for 5-10 minutes once or twice daily to soften crusts and warm meibomian secretions 1, 3
• Eyelid cleansing once or twice daily using diluted baby shampoo or commercially available eyelid cleaners 1
• Hypochlorous acid 0.01% eye cleaners provide strong antimicrobial effects for both anterior and posterior blepharitis 1, 3
• Vertical eyelid massage after warm compresses to express meibomian secretions, particularly for posterior blepharitis/MGD 1
• Artificial tears to manage associated dry eye symptoms, especially oil or lipid-containing products 1

Critical caveat: Avoid compresses that are too hot to prevent skin burns. 1 Patients with advanced glaucoma should avoid aggressive lid pressure during massage to prevent increased intraocular pressure. 3 Those with neurotrophic corneas require careful counseling to avoid corneal epithelial injury during cleansing. 3

Step 2: Add Topical Antibiotics (If Inadequate Response After 2-4 Weeks)

Topical antibiotic ointment should be added when first-line measures provide inadequate relief or when signs of bacterial infection are present. 1

Preferred Topical Antibiotics:

• Bacitracin ointment applied to lid margins 1-3 times daily (after removing all scales and crusts, spread uniformly over lid margins) 1, 4
• Erythromycin ointment applied to lid margins one or more times daily for a few weeks 1
• Azithromycin 1% ophthalmic solution has shown efficacy in reducing signs and symptoms 1, 5

Important resistance consideration: Use topical antibiotics intermittently with different medications to prevent development of resistant organisms; long-term antibiotic use may lead to resistant organisms. 1

Step 3: Systemic Antibiotics (For Severe or Resistant Cases)

When topical therapy fails or disease is moderate to severe:

For Adults:

• Doxycycline (standard regimen for severe cases) 1, 3
• Minocycline (alternative tetracycline) 3
• Azithromycin oral pulse regimen: 1 g per week for 3 weeks 1

For Children and Pregnant Women:

• Erythromycin (tetracyclines contraindicated in pregnancy, nursing women, and children under 8 years) 1, 3

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

These systemic antibiotics provide both antimicrobial and anti-inflammatory properties. 3

Step 4: Anti-Inflammatory Agents (For Marked Inflammation)

Short-Course Topical Corticosteroids:

• Loteprednol etabonate or fluorometholone phosphate are safer options due to site-specific action and limited ocular penetration 1
• Indicated for eyelid or ocular surface inflammation, including marginal keratitis or phlyctenules 1
• Use only for short courses to avoid complications 1, 6, 7

Alternative Anti-Inflammatory Options:

• Cyclosporine topical may be useful in posterior blepharitis and can help manage coexisting aqueous tear deficiency 1
• Tacrolimus 0.1% ointment applied once daily to external eyelids and lid margins for 2-4 weeks for atopic eyelid dermatitis (tacrolimus 0.03% for children aged 2-17 years) 3

Additional Treatment Considerations

Adjunctive Therapies:

• Omega-3 fatty acid supplements have mixed evidence but some studies show 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 Procedures (Recalcitrant Cases):

• Vectored thermal pulsation or microblepharoexfoliation may be considered for cases not responding to medical management 1, 2

Critical Patient Education Points

Patients must understand that blepharitis is typically chronic and cannot be permanently cured. 1 Complete cure is usually not possible, and long-term management is required as symptoms often recur when treatment is discontinued. 1 Daily eyelid hygiene is essential for long-term control and must be continued indefinitely. 1 Successful management depends on long-term treatment regimen compliance. 1