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 Condition

Blepharitis divides into two main categories that guide treatment selection:

• Anterior blepharitis affects the eyelid skin, eyelash base, 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 Algorithm

Step 1: Conservative Management (2-4 weeks)

Warm compresses:

• Apply for 5-10 minutes once or twice daily to soften crusts and warm meibomian secretions 1, 2
• Caution: Ensure compresses are not too hot to prevent skin burns 1
• Avoid aggressive pressure in patients with advanced glaucoma (risk of increased intraocular pressure) 2

Eyelid cleansing:

• Use diluted baby shampoo or commercially available eyelid cleaners once or twice daily 1
• Hypochlorous acid 0.01% cleaners provide strong antimicrobial effects for both anterior and posterior blepharitis 1, 2
• Apply with cotton pad, ball, swab, or clean fingertip 2
• Caution: Patients with neurotrophic corneas require careful counseling to avoid corneal epithelial injury during cleansing 2

Vertical eyelid massage:

• Perform after warm compresses to express meibomian secretions, particularly beneficial for posterior blepharitis/MGD 1, 2

Artificial tears:

• Use to manage associated dry eye symptoms, especially oil or lipid-containing products 1

Step 2: Add Topical Antibiotics (if inadequate response after 2-4 weeks)

Preferred first-line topical antibiotics:

• Bacitracin or erythromycin ointment applied to eyelid margins one or more times daily for a few weeks 1
• These reduce bacterial load in anterior blepharitis 2

Important antibiotic considerations:

• Use intermittently with different medications to prevent resistant organisms 1
• Ofloxacin is NOT first-line; reserve for confirmed bacterial infection or pre-surgical prophylaxis 1
• Long-term antibiotic use may lead to resistant organisms 1

Step 3: Systemic Antibiotics (for severe or resistant cases)

For adults:

• Doxycycline is the standard regimen for severe cases 1
• Alternative: Azithromycin oral pulse regimen (1 g per week for 3 weeks) 1
• Caution: Azithromycin may cause cardiac rhythm irregularities, especially in patients with high baseline cardiovascular risk 1

For children and pregnant women:

• Erythromycin (tetracyclines contraindicated in pregnancy, nursing, and children under 8 years) 1, 2
• For children 2-17 years with atopic eyelid dermatitis: tacrolimus 0.03% ointment, with option to increase to 0.1% under ophthalmology guidance 2

Mechanism: These medications provide both antimicrobial and anti-inflammatory properties 2

Additional Treatment Options

Short-term corticosteroids (for marked inflammation)

• Consider for eyelid or ocular surface inflammation, including marginal keratitis or phlyctenules 1
• Safer options: Loteprednol etabonate and fluorometholone phosphate due to site-specific action and limited ocular penetration 1
• Use short courses only to minimize side effects 1, 2

Advanced therapies for recalcitrant cases

• Cyclosporine topical may help with posterior blepharitis and coexisting aqueous tear deficiency 1
• Topical perfluorohexyloctane prevents tear evaporation and improves dry eye symptoms 1
• In-office procedures: Vectored thermal pulsation or microblepharoexfoliation for recalcitrant cases 1
• Tea tree oil 50% for Demodex infestation in patients not improving with previous treatments 1
• Lotilaner ophthalmic solution 0.25% is the first FDA-approved therapy specifically for Demodex blepharitis, eradicating mites in 50-67% of patients 3

Adjunctive therapies

• Omega-3 fatty acid supplements show mixed evidence but may improve tear break-up time, dry eye symptoms, and meibum score 1

Critical Patient Education Points

• Daily eyelid hygiene is essential for long-term control and must continue indefinitely 1
• Symptoms often recur when treatment is discontinued 1, 2
• Complete cure is usually not possible; successful management depends on long-term treatment compliance 1
• Frequency and duration should be guided by severity and treatment response 1