How should chronic blepharitis in an adult be treated, including lid hygiene, topical antibiotics, oral doxycycline, and steroid use?

Treatment of Chronic Blepharitis in Adults

Chronic blepharitis requires lifelong management with daily lid hygiene as the foundation, supplemented by topical antibiotics for anterior disease and oral doxycycline for posterior blepharitis/MGD when hygiene measures alone are insufficient, with short-term topical steroids reserved for significant inflammation. 1

Patient Education: Setting Realistic Expectations

• Blepharitis is typically chronic and cannot be permanently cured—patients must understand that successful management depends on long-term compliance with treatment regimens, as symptoms often recur when treatment is discontinued. 1
• Worsening symptoms in the morning are typical of blepharitis, whereas worsening later in the day suggests aqueous deficient dry eye. 1

First-Line Treatment: Lid Hygiene (Essential for All Types)

Begin with daily warm compresses and eyelid cleansing for 2-4 weeks before escalating therapy. 1, 2

Warm Compresses

• Apply warm compresses to eyelids for several minutes to soften adherent crusts and warm meibomian secretions. 1
• Use hot tap water on a clean washcloth, over-the-counter heat pack, or homemade bean/rice bag heated in microwave. 1
• Critical pitfall: Instruct patients to avoid compresses so hot they burn the skin. 1

Eyelid Cleansing

• Perform gentle eyelid massage using diluted baby shampoo or commercially available eyelid cleaners once or twice daily. 1, 2
• Hypochlorous acid 0.01% eye cleaners have strong antimicrobial effects for both anterior and posterior blepharitis and represent an evidence-based option. 1, 2
• For posterior blepharitis/MGD, add vertical eyelid massage to express meibomian secretions. 1, 3

Second-Line Treatment: Topical Antibiotics for Anterior Blepharitis

If inadequate response to lid hygiene after 2-4 weeks, add topical antibiotic ointment. 1, 2

• Apply bacitracin or erythromycin ointment to eyelid margins one or more times daily or at bedtime for a few weeks. 1, 2
• Topical antibiotics provide symptomatic relief and effectively decrease bacterial load from the eyelid margin in anterior blepharitis. 2, 4
• Rotate different antibiotics intermittently to prevent development of resistant organisms—long-term continuous antibiotic treatment may result in resistance. 1, 3

Topical Azithromycin Option

• For moderate to severe chronic blepharitis, topical azithromycin 1% ophthalmic solution can be applied twice daily for 2 days, then once daily for 12 days, combined with warm compresses. 2

Oral Antibiotics for Posterior Blepharitis/MGD

For posterior blepharitis/MGD with persistent symptoms not adequately controlled by eyelid cleansing, oral tetracyclines are recommended. 2

Doxycycline (First Choice for Adults)

• Standard regimen for severe posterior blepharitis/MGD. 2, 3
• Oral tetracyclines (doxycycline, minocycline) or macrolides (erythromycin, azithromycin) are recommended when symptoms persist despite hygiene measures. 2

Oral Azithromycin (Alternative When Tetracyclines Contraindicated)

• Oral azithromycin 500 mg daily for 3 days in three cycles with 7-day intervals between cycles has demonstrated good clinical improvement. 2
• Alternative pulse regimen: 1 g per week for 3 weeks. 3
• Critical cardiac warning: Oral azithromycin may cause abnormalities in cardiac electrical activity with potential for serious heart rhythm irregularities, particularly in patients with high baseline cardiovascular disease risk. 1, 2, 3
• Reserve oral azithromycin for cases where topical therapy fails and tetracyclines are contraindicated (children, pregnant women, women of childbearing age). 2

Evidence Limitations

• Very low certainty evidence suggests oral antibiotics may improve clinical signs (Schirmer's test, tear film break-up time) but may cause more adverse events. 5
• High-dose doxycycline (200 mg twice daily) increased serious side effects in 39% of participants versus 6% with placebo. 5

Topical Corticosteroids: Short-Term Use Only

Add short-course topical corticosteroids (1-2 weeks) for significant eyelid or ocular surface inflammation, including marginal keratitis or phlyctenules. 1, 3

• Loteprednol etabonate and fluorometholone phosphate are safer options due to their site-specific action and limited ocular penetration. 3
• Topical corticosteroid-antibiotic combinations may be effective for reducing signs and symptoms, but should be used for limited duration (1-2 weeks) to minimize steroid-related complications. 2
• Use minimal effective dose to avoid steroid-related complications (elevated intraocular pressure, cataracts). 3

Adjunctive Treatments

Artificial Tears

• Consider artificial tears to manage associated dry eye symptoms. 3
• If used more than 4 times daily, use preservative-free formulations to avoid toxicity. 2
• Topical perfluorohexyloctane can prevent tear evaporation and improve symptoms in patients with associated dry eye disease. 3

Cyclosporine

• Topical cyclosporine may be useful in some patients with posterior blepharitis and can help manage coexisting aqueous tear deficiency. 3

Omega-3 Fatty Acids

• Mixed evidence exists, with some studies showing improvement in tear break-up time, dry eye symptoms, and meibum score. 3

Special Populations Requiring Aggressive Management

• Patients with rosacea, atopy, psoriasis, or eczema commonly have associated blepharitis and may require more aggressive management. 3
• Rosacea patients often require more aggressive systemic therapy with oral antibiotics. 3

Pre-Surgical Considerations

• Consider addressing moderate to severe blepharitis with topical antibiotics and eyelid hygiene prior to intraocular surgical procedures to reduce risk of postoperative endophthalmitis. 1, 2
• In a large retrospective study, causative microorganisms of acute postoperative endophthalmitis included usual ocular surface pathogens commonly associated with blepharitis (coagulase-negative Staphylococcus 68.4%, S. aureus 6.8%, Streptococcus species 8.2%). 1
• However, there is no evidence proving that such treatment will prevent endophthalmitis. 1

Red Flags: When to Suspect Alternative Diagnoses

In patients with blepharitis who do not respond to therapy, consider carcinoma or immune-mediated diseases, particularly if associated with loss of eyelashes and/or conjunctival cicatricial changes. 1

• Discoid lupus erythematosus and ocular mucous membrane pemphigoid (OMMP) can masquerade as blepharoconjunctivitis. 1
• Early diagnosis and appropriate treatment can prevent vision loss, disfigurement, and may be lifesaving. 1

Treatment Algorithm Summary

1. Start: Daily warm compresses + eyelid cleansing (hypochlorous acid 0.01% preferred) for 2-4 weeks 1, 2
2. If inadequate response (anterior blepharitis): Add topical bacitracin or erythromycin ointment 2
3. If inadequate response (posterior blepharitis/MGD): Add oral doxycycline or oral azithromycin (if tetracyclines contraindicated, with cardiac risk assessment) 2, 3
4. For significant inflammation: Add short-term topical corticosteroids (1-2 weeks), preferably loteprednol or fluorometholone 3
5. Rotate antibiotics intermittently to prevent resistance 3
6. Frequency and duration guided by severity and response 3