What is the recommended treatment for scaly (seborrheic) blepharitis?

Treatment of Scaly (Seborrheic) Blepharitis

Begin with daily warm compresses and eyelid hygiene as first-line therapy, then escalate to topical antibiotic ointments (bacitracin or erythromycin) if symptoms persist after 2-4 weeks. 1

First-Line Treatment: Eyelid Hygiene Regimen

Daily eyelid hygiene must be maintained long-term, as this is a chronic condition without a definitive cure. 1

• 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, but avoid compresses hot enough to burn the skin 1
• 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
• For meibomian gland involvement, perform vertical eyelid massage to express meibomian gland secretions 1
• Maintain this regimen daily or several times weekly to control chronic symptoms 1

Adjunctive Therapy for Dry Eye Symptoms

• 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 if eyelid hygiene provides inadequate relief after 2-4 weeks. 1

• Apply bacitracin or erythromycin ointment 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
• Rotate different antibiotic classes intermittently to prevent development of resistant organisms 1, 3
• Adjust frequency and duration based on severity and treatment response 1
• Do not use topical antibiotics continuously long-term; apply intermittently for a few weeks at a time, with treatment repeated on an as-needed basis 3

Third-Line Treatment: Oral Antibiotics

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

• Use doxycycline, minocycline, or tetracycline given daily, then tapered after clinical improvement 1, 2
• For women of childbearing age and children under 8 years, use 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

Specialized Treatments for Refractory Cases

• Tea tree oil at 50% concentration can be considered for patients not improving with previous treatments, particularly for Demodex blepharitis 1
• Metronidazole and ivermectin are alternative antiparasitic options for Demodex blepharitis 1
• Topical perfluorohexyloctane can prevent tear evaporation and improve dry eye symptoms 1
• In-office procedures (vectored thermal pulsation, microblepharoexfoliation, intense pulsed light therapy) can be used for recalcitrant cases 1, 2
• Omega-3 fatty acid supplements show mixed evidence but may improve tear break-up time and meibum score 1

Short-Term Corticosteroid Use

• A short course of topical corticosteroids may be used for eyelid or ocular surface inflammation, including marginal keratitis or phlyctenules 2
• Loteprednol etabonate and fluorometholone phosphate are safer options due to their site-specific action and limited ocular penetration 2
• For severe cases, stronger potency steroids such as betamethasone may be recommended 1
• Long-term low-dose topical steroids are reserved only for patients with autoimmune diseases or moderate to severe dry eye disease 1

Critical Patient Education

Blepharitis is chronic and incurable; symptoms recur when treatment is discontinued. 1, 2, 3

• Long-term daily eyelid hygiene is essential for symptom control 1, 3
• Treatment requires persistence and often a trial-and-error approach 1
• Successful management depends on long-term treatment regimen compliance 2

Special Populations and Precautions

• Patients with advanced glaucoma should avoid aggressive lid pressure during massage, as this may increase intraocular pressure 1
• Patients with neurotrophic corneas should be counseled carefully to avoid corneal epithelial injury during eyelid cleansing 1
• Patients with rosacea, atopy, psoriasis, or eczema commonly have associated blepharitis and may require more aggressive management 2, 4
• Preoperative patients with moderate to severe blepharitis should be addressed with topical antibiotics and eyelid hygiene before intraocular surgery to reduce endophthalmitis risk 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