What is the treatment for blepharitis?

Treatment of Blepharitis

Begin with daily warm compresses and eyelid hygiene as first-line therapy for all blepharitis patients, then escalate to topical antibiotics if symptoms persist after 2-4 weeks. 1, 2

Initial Management: Eyelid Hygiene Regimen

The foundation of blepharitis treatment is a consistent eyelid hygiene routine that must be maintained long-term, as this is a chronic condition without a definitive cure 1, 2.

Warm Compresses

• Apply warm compresses to eyelids for several minutes once or twice daily 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 1
• Critical caveat: Instruct patients to avoid compresses hot enough to burn the skin 1, 2
• Warm compresses are especially effective for posterior blepharitis/meibomian gland dysfunction (MGD) 1, 2

Eyelid Cleansing

• Gently rub the base of eyelashes using diluted baby shampoo or commercially available eyelid cleaners on a pad, cotton ball, cotton swab, or clean fingertip 1
• Hypochlorous acid 0.01% eye cleaners provide strong antimicrobial effects for both anterior and posterior blepharitis 1, 2
• For MGD, perform vertical eyelid massage to express meibomian gland secretions 1, 2
• Maintain this regimen daily or several times weekly to control chronic symptoms 1

Artificial Tears

• Add artificial tears to manage associated dry eye symptoms 2
• Oil or lipid-containing products may provide additional benefit 2

Second-Line Treatment: Topical Antibiotics

If eyelid hygiene provides inadequate relief after 2-4 weeks, add topical antibiotics 2.

Topical Antibiotic Options

• Bacitracin or erythromycin ointment applied to eyelid margins one or more times daily or at bedtime for several weeks 1, 2
• Azithromycin in sustained-release formulation has demonstrated efficacy in reducing signs and symptoms 1, 2
• Topical tobramycin/dexamethasone suspension may reduce symptoms in uncontrolled studies 1

Important Antibiotic Considerations

• Rotate different antibiotic classes intermittently to prevent development of resistant organisms 1, 2
• Adjust frequency and duration based on severity and treatment response 1, 2
• Long-term antibiotic use risks creating resistant organisms 1, 2

Third-Line Treatment: Systemic Antibiotics

For MGD patients with inadequate response to eyelid hygiene and topical therapy, escalate to oral antibiotics 1, 2.

Oral Antibiotic Regimens

• Doxycycline, minocycline, or tetracycline given daily, then tapered after clinical improvement 1, 2
• Alternative: Oral erythromycin or azithromycin for women of childbearing age and children under 8 years 1, 2
• Azithromycin pulse regimen: 1 g per week for 3 weeks or 500 mg daily for 3 days in three cycles with 7-day intervals 1, 2
• Tetracyclines and macrolides provide both antimicrobial and anti-inflammatory effects 1

Tetracycline Contraindications and Side Effects

• Contraindicated in pregnancy, nursing women, children under 8 years (causes tooth staining), and patients with tetracycline hypersensitivity 1
• Side effects include photosensitization, gastrointestinal upset, vaginitis, rarely azotemia, and pseudotumor cerebri 1
• Decreases oral contraceptive effectiveness and potentiates warfarin effect 1
• Minocycline may stain skin, nails, sclera, teeth, conjunctiva, tongue, and bone 1

Azithromycin Cautions

• May cause cardiac rhythm abnormalities, especially in patients with high baseline cardiovascular risk 2

Anti-Inflammatory Therapy

Topical Corticosteroids

• Consider short courses for significant eyelid or ocular surface inflammation, including marginal keratitis or phlyctenules 2
• Loteprednol etabonate and fluorometholone phosphate are safer options due to site-specific action and limited ocular penetration 2

Topical Cyclosporine

• May benefit patients with posterior blepharitis and coexisting aqueous tear deficiency 2

Specialized Treatments

For Demodex Blepharitis

• Lotilaner ophthalmic solution 0.25% is the first FDA-approved therapy, eradicating Demodex mites in 50-67% of patients with benefits continuing through 1 year 3
• Tea tree oil at 50% concentration can be considered for patients not improving with previous treatments 2
• Metronidazole and ivermectin are alternative antiparasitic options 1

Additional Therapies

• Topical perfluorohexyloctane prevents tear evaporation and improves dry eye symptoms 1, 2
• In-office procedures (vectored thermal pulsation, microblepharoexfoliation) for recalcitrant cases 1, 2
• Omega-3 fatty acid supplements show mixed evidence but may improve tear break-up time and meibum score 2

Critical Patient Education Points

• Blepharitis is chronic and incurable; symptoms recur when treatment is discontinued 1, 2
• Long-term daily eyelid hygiene is essential for symptom control 1, 2
• Treatment requires persistence and often a trial-and-error approach 1

Special Populations

Patients with Advanced Glaucoma

• Advise against aggressive lid pressure during massage, as this may increase intraocular pressure 1

Patients with Neurotrophic Corneas

• Counsel carefully to avoid corneal epithelial injury during eyelid cleansing 1

Preoperative Patients

• Address moderate to severe blepharitis with topical antibiotics and eyelid hygiene before intraocular surgery to reduce endophthalmitis risk 1
• Blepharitis is a risk factor for endophthalmitis after intravitreal injection and bleb-related infection 1