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, escalating to topical antibiotics only if symptoms persist after 2-4 weeks or if bacterial infection is evident. 1, 2

Understanding the Condition

Blepharitis is a chronic inflammatory condition that cannot be cured—patients must understand this requires long-term management rather than expecting complete resolution. 1, 2 The condition divides into:

• Anterior blepharitis: affects eyelid skin, base of eyelashes, and follicles 2
• Posterior blepharitis (Meibomian Gland Dysfunction/MGD): affects the meibomian glands 2

First-Line Treatment Algorithm

Step 1: Warm Compresses and Eyelid Hygiene (All Patients)

Warm compresses should be applied for several minutes to soften crusts and warm meibomian secretions. 1, 2 Use hot tap water on a clean washcloth, over-the-counter heat packs, or microwaveable bean/rice bags—but critically, instruct patients to avoid temperatures that burn the skin. 1, 2

Eyelid cleansing involves: 1

• Gentle rubbing of eyelash bases using diluted baby shampoo or commercial eyelid cleaners on a pad, cotton ball, cotton swab, or clean fingertip 1, 2
• Hypochlorous acid 0.01% cleaners provide strong antimicrobial effects for both anterior and posterior blepharitis 1, 2
• For posterior blepharitis/MGD: vertical eyelid massage to express meibomian gland secretions 1, 2

Critical caveat: Patients lacking manual dexterity or those with neurotrophic corneas require modified approaches to avoid corneal injury. 1 Patients with advanced glaucoma should avoid aggressive lid pressure as it may increase intraocular pressure. 1

Frequency: Once or twice daily, continued long-term as symptoms recur when treatment stops. 1, 2

Step 2: Artificial Tears (Adjunctive)

Add artificial tears, especially oil or lipid-containing products, to manage associated dry eye symptoms. 2

Second-Line Treatment: Topical Antibiotics

If inadequate response after 2-4 weeks of eyelid hygiene, add topical antibiotic ointment: 2

• Bacitracin or erythromycin ointment applied to eyelid margins one or more times daily or at bedtime for several weeks 1, 2
• Topical azithromycin in sustained-release formulation has shown efficacy in reducing signs and symptoms 1, 2
• Topical tobramycin/dexamethasone suspension (off-label) may reduce signs and symptoms 1

Important practice point: Use antibiotics intermittently with different medications to prevent resistant organism development. 1, 2 Long-term antibiotic treatment risks creating resistant organisms. 1, 2

Third-Line Treatment: Systemic Antibiotics

For severe or persistent MGD/posterior blepharitis not controlled by eyelid hygiene and topical therapy: 1, 2

Adults:

• Doxycycline daily, tapered after clinical improvement 1, 2
• Minocycline or tetracycline as alternatives 1
• Sustained-release doxycycline preparations reduce gastrointestinal side effects 1
• Azithromycin pulse regimen: 1 gram weekly for 3 weeks 2

Women of childbearing age, pregnant/nursing women, and children under 8 years:

• Oral erythromycin or azithromycin (tetracyclines contraindicated due to tooth staining in children and pregnancy risks) 1, 2

Mechanism: Tetracyclines and macrolides decrease lipase production in S. epidermidis and S. aureus and provide anti-inflammatory effects. 1

Critical warnings: 1, 2

• Tetracyclines cause photosensitization, gastrointestinal upset, vaginitis, rarely azotemia
• May cause pseudotumor cerebri
• Decrease oral contraceptive effectiveness and potentiate warfarin
• Azithromycin may cause cardiac rhythm abnormalities, especially in patients with baseline cardiovascular risk

Anti-Inflammatory Therapy

Short-course topical corticosteroids for eyelid or ocular surface inflammation, including marginal keratitis or phlyctenules: 2

• Loteprednol etabonate or fluorometholone phosphate preferred due to site-specific action and limited ocular penetration 2

Topical cyclosporine may benefit some patients with posterior blepharitis and coexisting aqueous tear deficiency. 2

Additional Considerations

Omega-3 fatty acid supplements show mixed evidence but may improve tear break-up time, dry eye symptoms, and meibum scores. 2

Tea tree oil 50% concentration can be considered for Demodex-associated blepharitis in treatment-resistant cases. 2

Preoperative management: Address moderate to severe blepharitis with topical antibiotics and eyelid hygiene before intraocular surgery, as causative organisms of postoperative endophthalmitis (coagulase-negative Staphylococcus 68.4%, S. aureus 6.8%, Streptococcus 8.2%) commonly associate with blepharitis. 1, 2 However, no evidence proves this prevents endophthalmitis. 1

In-office procedures such as vectored thermal pulsation or microblepharoexfoliation may be considered for recalcitrant cases. 2

Common Pitfalls to Avoid

• Expecting cure rather than chronic management 1, 2
• Using compresses too hot, causing skin burns 2
• Prolonged continuous antibiotic use creating resistant organisms 1, 2
• Aggressive lid manipulation in glaucoma patients 1
• Prescribing tetracyclines to pregnant women, nursing mothers, or children under 8 years 1, 2