What are the treatment options for blepharitis?

Treatment of Blepharitis

Begin with daily warm compresses and eyelid hygiene using diluted baby shampoo or commercial eyelid cleaners, then add topical antibiotic ointment (bacitracin or erythromycin) to the eyelid margins if symptoms persist after 2-4 weeks. 1, 2

Initial Management: Eyelid Hygiene (First-Line for All Types)

Warm Compresses and Cleansing:

• Apply warm compresses once or twice daily to soften crusts and warm meibomian gland secretions 1, 2
• Gently rub the base of eyelashes using diluted baby shampoo or commercial eyelid cleaners on a cotton swab, pad, or clean fingertip 1
• Hypochlorous acid 0.01% eye cleaners provide strong antimicrobial effects for both anterior and posterior blepharitis 2
• This regimen must be continued long-term, as symptoms recur when treatment is discontinued 1

For Posterior Blepharitis/Meibomian Gland Dysfunction (MGD):

• Add vertical eyelid massage to express meibomian gland secretions after warm compresses 2
• Perform meibomian gland expression with care, avoiding aggressive pressure in patients with advanced glaucoma 1

Adjunctive Measures:

• Use artificial tears, particularly oil-containing or lipid products, for associated dry eye symptoms 2

Second-Line: Topical Antibiotics

When to Add Topical Antibiotics:

• Inadequate response to eyelid hygiene after 2-4 weeks 2
• Signs of bacterial infection 2
• Anterior blepharitis with significant bacterial colonization 1

Topical Antibiotic Options:

• Bacitracin ointment: Apply directly to eyelid margins 1-3 times daily after removing all scales and crusts 3
• Erythromycin ointment: Apply to eyelid margins one or more times daily or at bedtime for a few weeks 1
• Azithromycin (sustained release): Has shown efficacy in reducing signs and symptoms in manufacturer-sponsored studies 1, 2

Important Considerations:

• Use topical antibiotics intermittently with different medications to prevent resistant organisms 1, 2
• Frequency and duration should be guided by severity and response to treatment 1
• Topical antibiotics provide symptomatic relief and decrease bacterial load but evidence for complete cure is inconclusive 1, 4

Third-Line: Oral Antibiotics for Severe or Refractory Cases

Indications for Oral Antibiotics:

• Chronic symptoms inadequately controlled by eyelid cleansing and topical therapy 1
• Severe posterior blepharitis/MGD 1, 2
• Associated ocular rosacea 1

Oral Antibiotic Regimens:

• Doxycycline, minocycline, or tetracycline: Give daily and taper after clinical improvement 1, 2
• Oral erythromycin or azithromycin: Use in women of childbearing age and children under 8 years (tetracyclines contraindicated due to tooth staining) 1
• Azithromycin pulse regimen: 1 gram per week for 3 weeks, or 500 mg daily for 3 days in three cycles with 7-day intervals 1, 2

Mechanism and Rationale:

• Tetracyclines decrease lipase production in S. epidermidis and S. aureus and have anti-inflammatory activity 1
• Improve tear break-up time in patients with rosacea and MGD 1

Critical Warnings:

• Tetracyclines cause photosensitization, gastrointestinal upset, and may decrease oral contraceptive effectiveness or potentiate warfarin 1
• Contraindicated in pregnancy, nursing women, and children under 8 years 1
• Azithromycin may cause cardiac rhythm irregularities, especially in patients with high cardiovascular risk 2
• Minocycline can stain skin, nails, sclera, teeth, conjunctiva, and bone 1

Adjunctive Anti-Inflammatory Therapy

Short-Course Topical Corticosteroids:

• Consider for marked eyelid or ocular surface inflammation, marginal keratitis, or phlyctenules 2
• Loteprednol etabonate or fluorometholone phosphate are safer options due to limited ocular penetration 2
• Evidence for effectiveness remains inconclusive 1, 4

Topical Cyclosporine:

• May be useful in posterior blepharitis with coexisting aqueous tear deficiency 2

Topical Perfluorohexyloctane:

• Prevents tear evaporation and improves symptoms in patients with associated dry eye disease 2

Treatment Algorithm Summary

1. Start: Daily warm compresses + eyelid hygiene with diluted baby shampoo or hypochlorous acid cleaners 1, 2
2. After 2-4 weeks if inadequate response: Add topical bacitracin or erythromycin ointment to eyelid margins 2, 3
3. For persistent/severe cases: Add oral doxycycline (adults) or erythromycin (children/pregnant women) 1, 2
4. For marked inflammation: Consider short course of topical loteprednol or fluorometholone 2
5. For refractory cases: Consider in-office procedures (vectored thermal pulsation, microblepharoexfoliation) 2

Critical Patient Education Points

• Blepharitis is typically chronic and cannot be permanently cured; complete cure is usually not possible 2, 5
• Long-term daily eyelid hygiene is essential for symptom control 2
• Symptoms often recur when treatment is discontinued 1
• Treatments can be intermittently discontinued and reinstated based on severity and tolerance 1