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 conservative management. 1

Understanding the Condition

Blepharitis is a chronic, incurable inflammatory condition requiring lifelong management rather than expecting complete resolution. 1, 2 The disease affects either:

• Anterior blepharitis: eyelid skin, lash base, and follicles 2
• Posterior blepharitis (Meibomian Gland Dysfunction/MGD): meibomian glands 2

First-Line Treatment (Weeks 1-4)

Warm Compresses

• Apply warm compresses to eyelids for several minutes once or twice daily to soften crusts and warm meibomian secretions 1
• Use hot tap water on a clean washcloth, over-the-counter heat packs, or microwaveable bean/rice bags 1
• Critical caveat: Avoid compresses hot enough to burn the skin 1
• Particularly effective for posterior blepharitis/MGD 1

Eyelid Hygiene

• 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 for chronic symptom control 1

Adjunctive Measures

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

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

Topical Antibiotics

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

• Bacitracin or erythromycin ointment: Apply to eyelid margins one or more times daily or at bedtime for several weeks 1, 2, 3
• Per FDA labeling for bacitracin: Apply directly into the conjunctival sac 1-3 times daily; for blepharitis, carefully remove all scales and crusts, then spread uniformly over lid margins 3
• Azithromycin in sustained-release formulation: Demonstrated efficacy in reducing signs and symptoms 1, 2
• Topical tobramycin/dexamethasone suspension may reduce symptoms 1

Important Antibiotic Considerations

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

Short-Course Corticosteroids (When Indicated)

• Consider a short course of topical corticosteroids for 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
• For severe cases, stronger potency steroids such as betamethasone may be needed 1

Third-Line Treatment (Severe or Refractory Cases)

Oral Antibiotics

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

• Doxycycline, minocycline, or tetracycline: Give daily, then taper after clinical improvement 1, 2
• Alternative regimens 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, 2
• Tetracyclines and macrolides provide both antimicrobial and anti-inflammatory effects 1

Important cardiac warning: Azithromycin may cause abnormalities in heart electrical activity with potential for serious cardiac rhythm irregularities, especially in patients with high baseline cardiovascular risk 2

Specialized Treatments

Demodex Blepharitis

• Tea tree oil at 50% concentration for patients not improving with previous treatments 1, 2
• Metronidazole and ivermectin are alternative antiparasitic options 1
• Collarettes at the base of eyelashes are pathognomonic for Demodex blepharitis 4

Advanced Therapies

• Topical perfluorohexyloctane can prevent tear evaporation and improve dry eye symptoms 1, 2
• Cyclosporine topical may be useful for posterior blepharitis and coexisting aqueous tear deficiency 2
• In-office procedures (vectored thermal pulsation, microblepharoexfoliation, intense pulsed light therapy) for recalcitrant cases 1, 2
• Omega-3 fatty acid supplements show mixed evidence but may improve tear break-up time and meibum score 1, 2

Special Population Considerations

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

Associated Conditions

• Patients with rosacea, atopy, psoriasis, or eczema commonly have associated blepharitis and may require more aggressive management 2, 5
• Rosacea patients often require more aggressive systemic therapy with oral antibiotics 2

Environmental and Lifestyle Modifications

• Blink more frequently (>10 times/minute) when using computers or watching TV 1
• Avoid wind exposure and dry environments 1
• Air-conditioned environments increase dry eye disease risk 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
• Use moisture chamber spectacles/goggles for severe cases 1
• Consider overnight treatments such as ointment or moisture chamber devices 1

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, and treatment requires persistence with often a trial-and-error approach. 1, 2