What is the recommended 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 (bacitracin or erythromycin) if symptoms persist after 2-4 weeks, and reserve oral antibiotics (doxycycline) for meibomian gland dysfunction unresponsive to topical measures. 1

First-Line Treatment: Eyelid Hygiene (All Patients)

Daily eyelid hygiene forms the foundation of blepharitis management and must be maintained long-term, as this is a chronic condition without definitive cure. 2, 1

Warm Compresses

• Apply warm compresses to eyelids for several minutes once or twice daily using hot tap water on a clean washcloth, over-the-counter heat packs, or microwaveable bean/rice bags 1
• Warm compresses soften crusts and warm meibomian secretions, particularly effective for posterior blepharitis/meibomian gland dysfunction 2, 1
• Caution patients to avoid compresses hot enough to burn the skin 1

Eyelid Cleansing

• 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 2, 1
• Hypochlorous acid 0.01% eye cleaners provide strong antimicrobial effects for both anterior and posterior blepharitis 1
• For meibomian gland dysfunction, perform vertical eyelid massage to express meibomian gland secretions 1
• Maintain this regimen daily or several times weekly to control chronic symptoms 2, 1

Special Precautions

• Patients with advanced glaucoma should avoid aggressive lid pressure during massage, as this may increase intraocular pressure 1
• Patients with neurotrophic corneas require careful counseling to avoid corneal epithelial injury during eyelid cleansing 2, 1

Second-Line Treatment: Topical Antibiotics (After 2-4 Weeks)

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

Topical Antibiotic Options

• Bacitracin or erythromycin ointment applied to eyelid margins one or more times daily or at bedtime for several weeks is the recommended first-line antibiotic therapy 2, 1
• Per FDA labeling, bacitracin ointment should be applied directly to the lid margins 1-3 times daily after carefully removing all scales and crusts 3
• Azithromycin in sustained-release formulation has demonstrated efficacy in reducing signs and symptoms 2, 1
• Topical tobramycin/dexamethasone suspension may reduce symptoms, though evidence comes from uncontrolled manufacturer-sponsored studies 2

Antibiotic Stewardship

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

Third-Line Treatment: Oral Antibiotics (Refractory MGD)

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

Oral Antibiotic Regimens

• Doxycycline, minocycline, or tetracycline given daily, then tapered after clinical improvement is the standard regimen for adults 2, 1
• Tetracyclines and macrolides provide both antimicrobial and anti-inflammatory effects 1
• For women of childbearing age and children under 8 years: use oral erythromycin or azithromycin 2, 1
• 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
• Pediatric erythromycin dosing: 30-40 mg/kg divided over 3 doses for 3 weeks, then twice daily for 4-6 weeks 2
• Pediatric azithromycin dosing: 5 mg/kg daily for 2 months has shown benefit in small case series 2

Specialized Treatments for Specific Etiologies

Demodex Blepharitis

• Tea tree oil at 50% concentration can be considered for patients not improving with previous treatments 1, 4
• Metronidazole and ivermectin are alternative antiparasitic options 1
• Lotilaner ophthalmic solution 0.25% is the first FDA-approved therapy for Demodex blepharitis, eradicating mites in one-half to two-thirds of patients 5

Adjunctive Therapies

• Topical perfluorohexyloctane (FDA approved 2023) prevents tear evaporation and improves dry eye symptoms after 8 weeks of treatment 2, 1
• Selenium sulfide may improve meibomian gland function by breaking disulfide bonds and decreasing meibum viscosity 2
• Loteprednol etabonate 0.5%/tobramycin 0.3% suspension is safer than dexamethasone combinations due to lower risk of intraocular pressure rise and cataract progression 2

In-Office Procedures for Recalcitrant Cases

• Vectored thermal pulsation and microblepharoexfoliation can be used for cases unresponsive to medical therapy 1, 6
• Intense pulsed light therapy shows high Demodex eradication rates, though caution is needed in darkly pigmented individuals (above Fitzpatrick skin type IV) 4

Critical Patient Education

Patients must understand that blepharitis is chronic and incurable; symptoms recur when treatment is discontinued. 2, 1, 4

• Long-term daily eyelid hygiene is essential for symptom control 1, 4
• Symptoms can frequently be improved but are rarely eliminated 4
• Treatment requires persistence and often a trial-and-error approach 1
• Successful management depends on compliance with long-term treatment regimens 1, 4

Red Flag: Malignancy Consideration

In elderly patients with unresponsive, chronic, unilateral blepharitis or recurrent chalazia in the same location, suspect sebaceous carcinoma. 4

• Red flags include nodular mass, ulceration, extensive scarring, lash loss, or localized crusting and scaling 4
• This requires heightened vigilance and prompt biopsy if suspected 4

Preoperative Considerations

• Patients with moderate to severe blepharitis should be treated with topical antibiotics and eyelid hygiene before intraocular surgery to reduce endophthalmitis risk 1
• Blepharitis is a risk factor for endophthalmitis after intravitreal injection and bleb-related infection 1