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 lid care. 1

First-Line Treatment: Eyelid Hygiene Regimen

This is the foundation of blepharitis management and must be maintained long-term, as this is a chronic condition without a definitive cure. 1

Warm Compresses

• Apply warm compresses to closed eyelids for several minutes once or twice daily to soften crusts and warm meibomian gland secretions 1
• Use hot tap water on a clean washcloth, over-the-counter heat packs, or microwaveable bean/rice bags 1
• Ensure compresses are not hot enough to burn the skin 1
• Particularly effective for posterior blepharitis/meibomian gland dysfunction (MGD) 1

Eyelid Cleansing

• Gently rub the base of eyelashes using diluted baby shampoo or commercially available eyelid cleaners on a cotton 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
• For MGD specifically, perform vertical eyelid massage to express meibomian gland secretions 1
• Continue this regimen daily or several times weekly for chronic symptom control 1

Adjunctive Tear Support

• Use preservative-free artificial tears for patients with poor ocular surface condition or those using drops more than 4 times daily 1
• Consider lipid-containing supplements if meibomian gland dysfunction is present 1

Second-Line Treatment: Topical Antibiotics

Add topical antibiotics only after 2-4 weeks of inadequate relief from eyelid hygiene alone. 1

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 1

Critical Antibiotic Considerations

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

Third-Line Treatment: Oral Antibiotics

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

Oral Antibiotic Regimens

• Doxycycline, minocycline, or tetracycline given daily, then tapered after clinical improvement 1
• 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 OR 500 mg daily for 3 days in three cycles with 7-day intervals 1
• Tetracyclines and macrolides provide both antimicrobial and anti-inflammatory effects 1

Important Safety Note

• Very low certainty evidence suggests oral antibiotics may improve clinical signs but may cause more adverse events, including gastrointestinal symptoms and headaches 3
• High-dose doxycycline (200 mg twice daily) showed 39% serious side effect rate versus 6% with placebo 3

Specialized Treatments for Specific Etiologies

Demodex Blepharitis

• Tea tree oil at 50% concentration for patients not improving with previous treatments 1, 2
• Alternative antiparasitic options: metronidazole and ivermectin 1

Severe or Recalcitrant Cases

• Short course of topical corticosteroids (loteprednol etabonate or fluorometholone phosphate preferred due to safer profile) for eyelid or ocular surface inflammation 2
• Topical perfluorohexyloctane to prevent tear evaporation and improve dry eye symptoms 1, 2
• In-office procedures: vectored thermal pulsation, microblepharoexfoliation, intense pulsed light therapy 1
• Omega-3 fatty acid supplements show mixed evidence but may improve tear break-up time and meibum score 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
• Treatment requires persistence and often a trial-and-error approach 1
• Maintain consistent regimen even after symptom improvement 1

Special Population Precautions

High-Risk Patients

• Patients with advanced glaucoma: avoid 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 Considerations

• Patients with moderate to severe blepharitis should receive 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

Environmental and Lifestyle Modifications

• Blink more frequently (>10 times/minute) when using computers or watching TV 1
• Avoid wind exposure and dry environments 1
• Caution against certain cosmetics 1
• Consider Mediterranean-diet-oriented dietary modifications 1
• Do not independently purchase over-the-counter eye drops, as many contain preservatives or vasoconstricting agents 1