What are the symptoms and treatment options for squamous blepharitis?

Squamous Blepharitis: Symptoms and Treatment

Squamous blepharitis, also known as seborrheic blepharitis, is a chronic anterior eyelid inflammation characterized by scaling and crusting at the eyelash base that requires lifelong management with eyelid hygiene as the cornerstone of therapy. 1

Understanding Squamous (Seborrheic) Blepharitis

Squamous blepharitis is a form of anterior blepharitis that affects the eyelid skin, base of eyelashes, and eyelash follicles, distinguished from staphylococcal blepharitis by its characteristic greasy, flaky scales rather than hard crusts. 1

Clinical Symptoms

Patients with squamous blepharitis typically present with:

• Morning symptom predominance (worsening symptoms upon awakening, which helps distinguish it from aqueous deficient dry eye that worsens later in the day) 1, 2
• Burning, irritation, and redness of the eyelid margins 1, 2
• Crusting and scaling of eyelashes, particularly greasy or oily scales 1, 3
• Tearing and itching 1, 2
• Blurred or fluctuating vision 1, 2
• Eyelid sticking, especially in the morning 2
• Contact lens intolerance 2
• Photophobia and increased blinking frequency 2, 3

Physical Examination Findings

On slit-lamp examination, look for:

• Greasy scales and debris at the base of eyelashes (unlike the hard collarettes of staphylococcal blepharitis) 1
• Eyelid margin hyperemia and vascularization 1, 3
• Telangiectasia of lid margins 3
• Associated seborrheic dermatitis of the scalp, eyebrows, or malar areas 1, 4

Treatment Algorithm

First-Line Treatment (Start Here for All Patients)

Daily eyelid hygiene is the fundamental, non-negotiable treatment that must be continued indefinitely. 5, 2

• Warm compresses for 5-10 minutes once or twice daily to soften crusts and debris 5, 2
• Eyelid cleansing once or twice daily using:
  • Diluted baby shampoo (2-3 drops in ¼ cup warm water), OR 5
  • Commercially available eyelid cleaners, OR 5
  • Hypochlorous acid 0.01% cleaners (preferred due to strong antimicrobial effects) 5
• Artificial tears to manage associated dry eye symptoms, preferably oil-containing formulations 5

Continue this regimen for 2-4 weeks before escalating therapy. 5, 2

Second-Line Treatment (If Inadequate Response After 2-4 Weeks)

Add topical antibiotic ointment applied to eyelid margins: 5, 2

• Bacitracin ointment applied 1-3 times daily (after removing all scales and crusts, spread uniformly over lid margins) 6, OR
• Erythromycin ointment applied to lid margins once or more times daily 5

Use intermittently and rotate between different antibiotics to prevent development of resistant organisms. 5

Third-Line Treatment (For Persistent or Severe Cases)

If symptoms persist despite 2-4 weeks of topical antibiotics:

• Short course of topical corticosteroids for marked eyelid or ocular surface inflammation 5, 4

  • Loteprednol etabonate or fluorometholone phosphate are preferred due to safer side-effect profiles 5
  • Monitor intraocular pressure within a few weeks of starting corticosteroids 1

• Oral antibiotics for severe cases: 5

  • Doxycycline (standard regimen for adults) 5
  • Azithromycin 1g per week for 3 weeks (pulse regimen) 5
    • CRITICAL WARNING: Azithromycin may cause cardiac arrhythmias, especially in patients with cardiovascular disease 1, 5

Additional Adjunctive Therapies

• Topical cyclosporine may help in some patients with posterior involvement and coexisting aqueous tear deficiency 5
• Omega-3 fatty acid supplements have mixed evidence but may improve tear break-up time and meibum quality 5
• In-office procedures (vectored thermal pulsation, microblepharoexfoliation) for recalcitrant cases 5

Critical Pitfalls and Red Flags

When to Suspect Malignancy

Consider eyelid biopsy if: 1, 2

• Unilateral involvement with chronic unresponsiveness to therapy 1, 2
• Loss of eyelashes (ciliary madarosis) in a focal pattern 1
• Nodular mass, ulceration, or extensive scarring 1
• Recurrent chalazia in the same location 1

Basal cell carcinoma, squamous cell carcinoma, and sebaceous carcinoma can masquerade as chronic blepharitis. 1

Pre-Surgical Considerations

Address moderate to severe blepharitis before intraocular surgery with topical antibiotics and eyelid hygiene to reduce endophthalmitis risk, as ocular surface pathogens associated with blepharitis (coagulase-negative Staphylococcus, S. aureus) are common causative organisms. 1, 2

Patient Education Essentials

Patients must understand that squamous blepharitis is a chronic condition that cannot be permanently cured and requires lifelong daily eyelid hygiene for symptom control. 1, 5 Symptoms typically improve but are rarely eliminated completely, and recurrence is expected when treatment is discontinued. 1, 5

Avoid compresses that are too hot to prevent skin burns. 5