What is the recommended treatment for a patient with a chalazion, considering their potential history of blepharitis or rosacea?

Chalazion Treatment

First-Line Treatment: Conservative Management

Start all chalazia with warm compresses applied for 5-10 minutes, 3-4 times daily, combined with eyelid hygiene and gentle massage—this approach resolves approximately 46-58% of cases within 3-6 weeks. 1, 2, 3

Conservative Therapy Protocol

• Apply warm compresses to the affected eyelid for 5-10 minutes, 3-4 times daily, using hot tap water on a clean washcloth, over-the-counter heat packs, or a microwaveable bean/rice bag 4, 1
• Perform gentle massage of the affected area immediately after warm compresses to express the obstructed meibomian gland 1, 5, 6
• Clean eyelid margins with diluted baby shampoo or commercial eyelid cleansers (hypochlorous acid 0.01% has strong antimicrobial effects) 4, 1
• Instruct patients to avoid compresses hot enough to burn the skin 4

Critical timing consideration: Chalazia present for less than 2 months respond significantly better to conservative therapy than older lesions (mean 1.5 months for resolved lesions versus 2.2 months for persistent lesions). 3

Topical Medications (Optional Adjunct)

• Topical antibiotics (tobramycin) or antibiotic-steroid combinations (tobramycin/dexamethasone) may be added to warm compresses, though they show no significant advantage over warm compresses alone for complete resolution 3
• All three approaches (warm compresses alone, with tobramycin, or with tobramycin/dexamethasone) achieved similar complete resolution rates of 16-21% 3

Second-Line Treatment: Intralesional Steroid Injection

Do not continue conservative management beyond 4-6 weeks without reassessment—escalate to intralesional triamcinolone acetonide injection, which achieves 84-94% resolution rates. 1, 5, 6, 2, 7

Injection Protocol

• Inject 0.2-0.3 mL of triamcinolone acetonide (10 mg/mL) directly into the lesion 2, 7
• This approach is nearly as effective as surgical incision and curettage (84% versus 87% resolution) but causes less pain and patient inconvenience 2
• Re-evaluate within a few weeks to assess response and check intraocular pressure 1

Common pitfall: Hypopigmentary skin changes can occur at the injection site, particularly in patients with darker skin 1, 7

Third-Line Treatment: Surgical Incision and Curettage

• Reserve for chalazia that fail intralesional steroid injection or when immediate resolution is required 2, 8
• Achieves 87% resolution but causes more pain than steroid injection 2

CRITICAL RED FLAGS: When to Biopsy

Always biopsy to exclude sebaceous carcinoma in the following scenarios—this is potentially life-saving:

• Recurrence in the same location, especially in elderly patients 1, 5, 6
• Marked asymmetry or resistance to standard therapy 1, 5, 6
• Unifocal recurrent chalazia unresponsive to therapy 1, 5
• Atypical features including eyelid margin distortion, focal lash loss, or ulceration 1, 5, 6
• Unilateral chronic blepharitis unresponsive to therapy 1, 5

The most critical error is prolonging conservative management beyond 4-6 weeks without reassessment in elderly patients with recurrent or unilateral lesions, as this delays diagnosis of sebaceous carcinoma. 1, 5, 6

Address Underlying Conditions

• Treat any associated bacterial blepharitis or meibomian gland dysfunction before addressing the chalazion, as these are common predisposing factors 1, 5, 6
• Evaluate for meibomian gland dysfunction, rosacea, or seborrheic dermatitis in patients with recurrent chalazia 1, 6
• Institute regular eyelid hygiene with warm compresses and eyelid cleansing for patients with blepharitis 4
• Consider systemic antibiotics for severe underlying blepharitis 1

Pediatric Considerations

• Evaluate children with chalazia for chronic blepharokeratoconjunctivitis, which often presents with recurrent conjunctivitis, keratitis, neovascularization, and eyelid inflammation 1, 5, 6
• Refer to ophthalmology if there is visual loss, moderate/severe pain, or severe/chronic redness 1

Emerging Treatment Options

• Intense pulsed light (IPL) with meibomian gland expression shows promise for recurrent multiple chalazia resistant to conventional therapy 1, 5, 6
• Use IPL with caution in darkly pigmented individuals (above Fitzpatrick skin type IV) due to risk of burns and pigmentation changes 1, 6

Prevention Strategies

• Maintain regular eyelid hygiene for patients prone to recurrent chalazia, especially those with blepharitis or meibomian gland dysfunction 1, 5, 6
• Treat underlying skin conditions such as rosacea or seborrheic dermatitis 1, 5, 6
• Avoid eye makeup during active inflammation 1, 5