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, escalating to topical antibiotics only if symptoms persist after 2-4 weeks of consistent eyelid care. 1, 2

Understanding the Condition

Blepharitis divides into two anatomic categories that guide treatment selection:

• Anterior blepharitis affects the eyelid skin, eyelash base, 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, 2

First-Line Treatment: Eyelid Hygiene (Weeks 1-4)

Warm compresses should be applied 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 2
• Caution patients to avoid compresses hot enough to burn the skin 1, 2
• Particularly effective for posterior blepharitis/MGD 2

Eyelid cleansing must be performed daily using one of these methods 1, 2:

• Diluted baby shampoo applied with a pad, cotton ball, cotton swab, or clean fingertip to gently rub the base of eyelashes 2
• Commercially available eyelid cleaners 1, 2
• Hypochlorous acid 0.01% eye cleaners provide strong antimicrobial effects for both anterior and posterior blepharitis 1, 2

For MGD specifically, perform vertical eyelid massage to express meibomian gland secretions 1, 2

Artificial tears help manage associated dry eye symptoms, especially oil or lipid-containing products 1

Second-Line Treatment: Topical Antibiotics (After 2-4 Weeks)

Add topical antibiotics only when eyelid hygiene provides inadequate relief after 2-4 weeks 1, 2:

• 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 2
• Rotate different antibiotic classes intermittently to prevent development of resistant organisms 1, 2
• Long-term antibiotic use risks creating resistant organisms 1, 2

Third-Line Treatment: Oral Antibiotics (For Severe/Resistant Cases)

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

For adults:

• Doxycycline, minocycline, or tetracycline given daily, then tapered after clinical improvement 1, 2
• Tetracyclines provide both antimicrobial and anti-inflammatory effects 2

For women of childbearing age and children under 8 years:

• Oral erythromycin or azithromycin 1, 2
• Azithromycin pulse regimen: 1 g per week for 3 weeks 1, 2
• Alternative: 500 mg daily for 3 days in three cycles with 7-day intervals 2
• Azithromycin may cause cardiac rhythm irregularities, especially in patients with high baseline cardiovascular risk 1

Adjunctive Treatments

Short-course topical corticosteroids for eyelid or ocular surface inflammation, including marginal keratitis or phlyctenules 1:

• Loteprednol etabonate and fluorometholone phosphate are safer options due to site-specific action and limited ocular penetration 1
• Topical tobramycin/dexamethasone combination addresses both infectious and inflammatory components 2

Cyclosporine topical may be useful in posterior blepharitis patients and can help manage coexisting aqueous tear deficiency 1

Omega-3 fatty acid supplements show mixed evidence but may improve tear break-up time, dry eye symptoms, and meibum score 1

Topical perfluorohexyloctane can prevent tear evaporation and improve dry eye symptoms 1, 2

Specialized Treatments for Demodex Blepharitis

Tea tree oil at 50% concentration can be considered for patients not improving with previous treatments 1, 2

Alternative antiparasitic options include metronidazole and ivermectin 2

In-Office Procedures for Recalcitrant Cases

Vectored thermal pulsation or microblepharoexfoliation may be considered when conservative measures fail 1, 2

Special Population Considerations

Patients with advanced glaucoma should avoid aggressive lid pressure during massage, as this may increase intraocular pressure 2

Patients with neurotrophic corneas should be counseled carefully to avoid corneal epithelial injury during eyelid cleansing 2

Preoperative patients with moderate to severe blepharitis should receive topical antibiotics and eyelid hygiene before intraocular surgery to reduce endophthalmitis risk 1, 2

Critical Patient Education

Patients must understand that 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
• Maintain this regimen daily or several times weekly to control chronic symptoms 2
• Treatment requires persistence and often a trial-and-error approach 2
• Successful management depends on long-term treatment regimen compliance 1