What is the treatment (Tx) of blepharitis?

Treatment of Blepharitis

Begin with daily warm compresses and eyelid hygiene as the foundation of treatment for all blepharitis patients, then escalate to topical antibiotics if symptoms persist after 2-4 weeks, reserving oral antibiotics for severe posterior blepharitis/MGD refractory to first-line measures. 1

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 staphylococcal or seborrheic in nature 1, 2
• Posterior blepharitis (Meibomian Gland Dysfunction/MGD): Affects the meibomian glands, often seborrheic, obstructive, or mixed 1, 2

Critical caveat: Blepharitis is typically chronic and cannot be permanently cured—symptoms often recur when treatment is discontinued, requiring long-term management rather than expecting complete resolution 3, 1

First-Line Treatment: Eyelid Hygiene (All Patients)

Start here for every patient, as this provides symptomatic relief for both anterior and posterior blepharitis 3, 1:

• Warm compresses: Apply once or twice daily to soften crusts and warm meibomian secretions 3, 1

  • Caution: Ensure compresses are not too hot to prevent skin burns 1
  • Glaucoma patients: Advise against aggressive lid pressure, as this may increase intraocular pressure 3

• Eyelid cleansing: Use diluted baby shampoo or commercially available eyelid cleaners once or twice daily 1

  • Hypochlorous acid 0.01% cleaners have strong antimicrobial effects for both anterior and posterior blepharitis 1

• Meibomian gland expression: For posterior blepharitis/MGD, vertical eyelid massage helps express secretions 1

• Artificial tears: Especially oil or lipid-containing products for associated dry eye symptoms 1

Duration: This regimen must be continued long-term, as symptoms recur when discontinued 3, 1

Second-Line Treatment: Topical Antibiotics

Add topical antibiotics if inadequate response to eyelid hygiene after 2-4 weeks 1:

Application Technique

• Bacitracin or erythromycin ointment: Apply 1 cm ribbon directly to eyelid margins where lashes emerge, NOT into the conjunctival sac 1, 4, 5
• Frequency: One or more times daily or at bedtime for a few weeks 3, 4
• For blepharitis: Remove all scales and crusts first, then spread ointment uniformly over lid margins 5

Evidence and Rationale

Topical antibiotics provide symptomatic relief and effectively decrease bacteria from the eyelid margin in anterior blepharitis 3

Important Considerations

• Rotate antibiotics intermittently using different mechanisms of action to prevent resistant organisms 3, 1
• Adjust frequency and duration based on severity and clinical response 3, 4
• Off-label options: Topical azithromycin in sustained release or tobramycin/dexamethasone suspension may reduce signs and symptoms, though evidence comes from manufacturer-sponsored uncontrolled studies 3

Third-Line Treatment: Oral Antibiotics

Reserve for posterior blepharitis/MGD with chronic symptoms inadequately controlled by eyelid cleansing and meibomian gland expression 3:

First-Choice Oral Antibiotics

• Doxycycline, minocycline, or tetracycline: Give daily, then taper after clinical improvement 3
  • Sustained-release doxycycline preparations reduce side effects 3
  • Mechanism: Decrease lipase production in S. epidermidis and S. aureus, plus anti-inflammatory activity 3

Alternative Oral Antibiotics (Special Populations)

• Oral erythromycin or azithromycin: Use in women of childbearing age and children under 8 years 3, 1
  • Pediatric erythromycin: 30-40 mg/kg divided over 3 doses for 3 weeks, then twice daily for 4-6 weeks 4
  • Azithromycin pulse regimen: 1 g per week for 3 weeks 1

Critical Safety Warnings

Tetracyclines 3:

• Contraindicated in pregnancy, nursing women, and children under 8 years (tooth staining)
• Side effects: Photosensitization, GI upset, vaginitis, rarely azotemia
• Drug interactions: Decrease oral contraceptive effectiveness, potentiate warfarin
• Associated with pseudotumor cerebri
• Minocycline may stain skin, nails, sclera, teeth, conjunctiva, tongue, and bone

Azithromycin 3, 1:

• FDA warning (March 2013): May cause abnormalities in heart electrical activity with potential for serious cardiac rhythm irregularities
• Tennessee Medicaid cohort showed increased cardiovascular deaths (hazard ratio 2.88), most pronounced in patients with high baseline cardiovascular risk
• Use with extreme caution in patients with cardiovascular disease

Adjunctive Treatments

Topical Corticosteroids

• Short course only for eyelid or ocular surface inflammation, including marginal keratitis or phlyctenules 1
• Safer options: Loteprednol etabonate and fluorometholone phosphate (site-specific action, limited ocular penetration) 1
• Critical pitfall: Rule out infectious keratitis before starting steroids, as they can worsen certain infections 6
• Evidence limitation: Effectiveness remains inconclusive per systematic review 3

Additional Options

• Cyclosporine topical: May help posterior blepharitis and coexisting aqueous tear deficiency 1
• Omega-3 fatty acid supplements: Mixed evidence, some studies show improvement in tear break-up time and meibum score 1
• Tea tree oil (50% concentration): Consider for Demodex in patients not improving with previous treatments 1
• Perfluorohexyloctane topical: Prevents tear evaporation in associated dry eye disease 1

In-Office Procedural Treatments

Consider for recalcitrant cases 1:

• Vectored thermal pulsation
• Microblepharoexfoliation

Special Clinical Scenarios

Preoperative Management

Address moderate to severe blepharitis before intraocular surgery to reduce endophthalmitis risk 4

• Consider ofloxacin when preparing for surgery, though not first-line for routine blepharitis 1

Progression to Preseptal Cellulitis

If blepharitis progresses to preseptal cellulitis (deeper tissue infection) 6:

• Immediate oral antibiotics required: Amoxicillin-clavulanate or cephalexin (5-10 days)
• Do NOT treat with topical antibiotics alone—systemic therapy is mandatory
• Consider hospitalization with IV antibiotics if systemic signs present

Treatment Algorithm Summary

1. All patients: Start warm compresses + eyelid hygiene + artificial tears 1
2. After 2-4 weeks if inadequate response: Add topical bacitracin or erythromycin ointment to lid margins 1
3. Severe/resistant posterior blepharitis: Add oral doxycycline (adults) or erythromycin (children/pregnant women) 3, 1
4. Recalcitrant cases: Consider in-office procedures, cyclosporine, or omega-3 supplements 1

Common Pitfalls to Avoid

• Do not expect cure: Educate patients that blepharitis is chronic and requires ongoing management 3, 1
• Do not apply antibiotic ointment into conjunctival sac: Target is the eyelid margin where bacterial colonization occurs 4
• Do not use long-term continuous antibiotics: Rotate intermittently to prevent resistance 3, 1
• Do not start steroids without ruling out infection: Can worsen infectious keratitis 6
• Do not use tetracyclines in pregnancy or children under 8: Use erythromycin or azithromycin instead 3, 4