What is the recommended 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 presents in two main forms that guide treatment selection:

• Anterior blepharitis affects the eyelid skin, base of eyelashes, 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: Eyelid Hygiene (All Patients)

• Apply warm compresses 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
• Perform gentle 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
• For posterior blepharitis/MGD, add vertical eyelid massage after warm compresses to express meibomian secretions 1, 2

Step 2: Artificial Tears

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

Step 3: Continue for 2-4 Weeks

• Maintain this regimen for 2-4 weeks before escalating treatment 1

Second-Line Treatment (Inadequate Response After 2-4 Weeks)

Topical Antibiotics

Add topical antibiotic ointment to eyelid margins one or more times daily for a few weeks if first-line measures provide inadequate relief: 1

• Bacitracin or erythromycin ointment are the recommended first-line antibiotic options 1
• Azithromycin has shown efficacy in reducing signs and symptoms 1
• Ofloxacin should be reserved for confirmed bacterial infection or when preparing for intraocular surgery 1

Critical caveat: Use topical antibiotics intermittently with different medications to prevent development of resistant organisms 1

Third-Line Treatment (Severe or Resistant Cases)

Oral Antibiotics

For moderate to severe cases not responding to topical therapy: 2

• Adults: Doxycycline or minocycline (tetracyclines) 1, 2
• Alternative regimen: Azithromycin oral pulse - 1 g per week for 3 weeks 1
• Children under 8 years, pregnant women, or nursing mothers: Erythromycin (tetracyclines are contraindicated) 1, 2

Important warning: Azithromycin may cause cardiac rhythm irregularities, especially in patients with high baseline cardiovascular risk 1

Short-Course Topical Corticosteroids

Consider for marked eyelid or ocular surface inflammation, including marginal keratitis or phlyctenules: 1

• Loteprednol etabonate or fluorometholone phosphate are safer options due to site-specific action and limited ocular penetration 1
• Use only for short courses to avoid complications 1

Additional Treatment Options

For Persistent Cases

• Cyclosporine topical may help patients with posterior blepharitis and coexisting aqueous tear deficiency 1
• Topical perfluorohexyloctane can prevent tear evaporation and improve dry eye symptoms 1
• Omega-3 fatty acid supplements have mixed evidence but may improve tear break-up time and meibum score 1

For Demodex Infestation

• Tea tree oil at 50% concentration can be considered for 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

In-Office Procedures (Recalcitrant Cases)

• Vectored thermal pulsation or microblepharoexfoliation may be considered 1

Special Population Considerations

• Patients with advanced glaucoma: Avoid aggressive lid pressure during massage to prevent increased intraocular pressure 2
• Patients with neurotrophic corneas: Counsel carefully to avoid corneal epithelial injury during cleansing 2
• Dupilumab-related ocular surface disorders: Lubricants and tacrolimus ointment are particularly effective 2

Critical Patient Education Points

• Daily eyelid hygiene is essential for long-term control and must be continued indefinitely 1
• Symptoms often recur when treatment is discontinued 1, 2
• Complete cure is usually not possible; this is a chronic condition requiring ongoing management 1