What is the treatment for blepharitis?

Treatment of Blepharitis

Begin with daily warm compresses and eyelid hygiene as first-line therapy for all types of blepharitis, then escalate to topical antibiotics (bacitracin or erythromycin ointment) if inadequate response after 2-4 weeks, and reserve oral antibiotics (doxycycline or tetracyclines) for severe posterior blepharitis/meibomian gland dysfunction unresponsive to conservative measures. 1, 2

Understanding the Disease

Blepharitis is classified into two anatomical types that guide treatment selection 1:

• Anterior blepharitis: Affects the eyelid skin, base of eyelashes, and follicles, typically bacterial (staphylococcal) or seborrheic in nature 1
• Posterior blepharitis (Meibomian Gland Dysfunction/MGD): Affects the meibomian glands with obstruction and abnormal secretions 1

Critical caveat: Blepharitis is typically chronic and cannot be permanently cured; symptoms recur when treatment is discontinued, so patients must understand this requires ongoing long-term management rather than expecting complete resolution 3, 1, 2

First-Line Treatment Algorithm

Step 1: Eyelid Hygiene (All Patients)

Warm compresses 3, 1, 2:

• Apply for several minutes once or twice daily to soften crusts and warm meibomian secretions 3, 1
• Warning: Ensure compresses are not too hot to prevent skin burns 1
• Patients with advanced glaucoma should avoid aggressive lid pressure as it may increase intraocular pressure 3

Eyelid cleansing 3, 1, 2:

• Gently rub the base of eyelashes using diluted baby shampoo or commercially available eyelid cleaner on a pad, cotton ball, or clean fingertip 3
• Hypochlorous acid 0.01% eye cleaners have strong antimicrobial effects for both anterior and posterior blepharitis 1, 2
• For anterior blepharitis, carefully remove all scales and crusts before applying treatment 4
• Continue daily or several times weekly long-term to control chronic symptoms 3

Meibomian gland expression (for posterior blepharitis/MGD) 3, 1:

• Perform vertical eyelid massage to express meibomian secretions 1
• Must be done with care to avoid mechanically induced irritation 3

Artificial tears 1:

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

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

For anterior blepharitis 3, 2, 4:

• Bacitracin or erythromycin ointment applied to eyelid margins one or more times daily or at bedtime for a few weeks 3, 2
• FDA-approved dosing for bacitracin: Apply directly into the conjunctival sac 1 to 3 times daily, spreading uniformly over lid margins after removing scales and crusts 4
• Topical antibiotics decrease bacterial load and provide symptomatic relief 3, 2

Important practice point: Rotate different antibiotic medications intermittently with different mechanisms of action to prevent development of resistant organisms 3, 2

Alternative topical options (off-label, manufacturer-sponsored studies) 3:

• Azithromycin in sustained release system has shown efficacy in reducing signs and symptoms 3, 1
• Tobramycin/dexamethasone suspension may reduce signs and symptoms 3

Step 3: Oral Antibiotics (For Severe/Persistent Posterior Blepharitis/MGD)

When chronic symptoms and signs are not adequately controlled by eyelid cleansing or meibomian gland expression 3, 2:

Adult patients 3, 1, 2:

• Doxycycline, minocycline, or tetracycline given daily, then tapered after clinical improvement 3, 2
• Doxycycline is the standard regimen for severe cases 1
• Sustained-release doxycycline preparation can reduce side effects 3
• Mechanism: Tetracyclines decrease lipase production in S. epidermidis and S. aureus, and have anti-inflammatory activity 3

Women of childbearing age and children 3, 2:

• Erythromycin or azithromycin as alternatives 3, 2
• Azithromycin oral pulse regimen: 1 g per week for 3 weeks 1
• Contraindication: Tetracyclines should not be used in children under 8 years (tooth staining), pregnancy, or nursing women 3

Tetracycline warnings 3, 1:

• Can cause photosensitization, gastrointestinal upset, vaginitis, rarely azotemia 3
• Implicated in pseudotumor cerebri cases 3
• May decrease effectiveness of oral contraceptives and potentiate warfarin effect 3
• Azithromycin may cause cardiac rhythm abnormalities, especially in patients with high baseline cardiovascular risk 1

Treatment pattern: Can be intermittently discontinued and reinstated based on severity and medication tolerance 3

Adjunctive Therapies

Short-Term Anti-Inflammatory Treatment

Topical corticosteroids 1, 2:

• Consider for eyelid or ocular surface inflammation, including marginal keratitis or phlyctenules 1
• Use for limited duration (1-2 weeks) to minimize steroid-related complications 2
• Safer options: Loteprednol etabonate and fluorometholone phosphate due to site-specific action and limited ocular penetration 1
• Corticosteroid-antibiotic combinations may be effective but evidence is inconclusive 3, 2

Additional Options for Refractory Cases

Cyclosporine topical 1:

• May be useful in some patients with posterior blepharitis and coexisting aqueous tear deficiency 1

Perfluorohexyloctane 1:

• Can prevent tear evaporation and improve symptoms in patients with associated dry eye disease 1

Omega-3 fatty acid supplements 1:

• Mixed evidence; some studies show improvement in tear break-up time, dry eye symptoms, and meibum score 1

Tea tree oil 1:

• 50% concentration can be considered for Demodex treatment in patients who do not improve with previous treatments 1

In-office procedures 1:

• Vectored thermal pulsation or microblepharoexfoliation may be considered for recalcitrant cases 1

Special Considerations

Preoperative management 1, 2:

• Address moderate to severe blepharitis prior to intraocular surgery to reduce risk of postoperative endophthalmitis 2
• Consider antibiotics like ofloxacin when preparing for intraocular surgery 1

Patient dexterity concerns 3:

• Eyelid cleaning and digital massage can be dangerous if patient lacks manual dexterity, skill, or judgment 3
• Tailor therapeutic plan to patient's ability to perform treatment safely 3

Neurotrophic corneas 3:

• Proper counseling is important to avoid injury to corneal epithelium during eyelid hygiene 3

Evidence Quality Note

A Cochrane systematic review reported uncertainty regarding effectiveness of both topical and systemic treatments for blepharokeratoconjunctivitis in children due to lack of high-quality evidence, highlighting the need for individualized clinical judgment in pediatric cases 2