What is the recommended treatment regimen for blepharitis?

Blepharitis Management

Recommended Treatment Algorithm

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 consistent lid hygiene. 1

First-Line Treatment (All Patients)

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 2, 1
• Ensure compresses are not hot enough to burn the skin 2, 1
• Warm compresses are particularly effective for posterior blepharitis and meibomian gland dysfunction (MGD) by softening meibomian secretions 2, 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 MGD specifically, perform vertical eyelid massage to express meibomian gland secretions 2, 1
• Rub eyelid margins side to side to remove crusting from eyelashes 2

Critical Patient Education:

• Patients must understand that blepharitis is chronic and incurable—symptoms will recur when treatment is discontinued 2, 1, 3
• Long-term daily eyelid hygiene is essential for symptom control and must be maintained indefinitely 1, 3

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

Add topical antibiotics if eyelid hygiene provides insufficient relief: 1

• Bacitracin or erythromycin ointment applied to eyelid margins one or more times daily or at bedtime for several weeks 1, 3
• Azithromycin in sustained-release formulation has demonstrated efficacy in reducing signs and symptoms 1
• Rotate different antibiotic classes intermittently to prevent development of resistant organisms 1

Important Caveat: Long-term antibiotic use risks creating resistant organisms, so use judiciously and intermittently 2, 1, 3

Third-Line Treatment (Refractory Cases)

For MGD patients with inadequate response to eyelid hygiene and topical therapy:

• Oral doxycycline, minocycline, or tetracycline given daily, then tapered after clinical improvement 1
• For women of childbearing age and children under 8 years: oral erythromycin or azithromycin 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
• Tetracyclines and macrolides provide both antimicrobial and anti-inflammatory effects 1

Specialized Treatments

For Demodex blepharitis:

• Tea tree oil at 50% concentration for patients not improving with previous treatments 1
• Alternative antiparasitic options include metronidazole and ivermectin 1

For severe inflammation:

• Short course of topical corticosteroids for eyelid or ocular surface inflammation, including marginal keratitis or phlyctenules 3
• Loteprednol etabonate and fluorometholone phosphate are safer options due to limited ocular penetration 3
• Topical cyclosporine may be useful in posterior blepharitis with coexisting aqueous tear deficiency 3

In-office procedures for recalcitrant cases:

• Vectored thermal pulsation or microblepharoexfoliation 1, 3
• Physical heating and expression of meibomian glands 1
• Intense pulsed light therapy 1

Adjunctive Therapies

For associated dry eye symptoms:

• Preservative-free artificial tears for patients using drops more than 4 times daily 1
• Lipid-containing supplements if MGD is present 1
• Topical perfluorohexyloctane to prevent tear evaporation 1, 3

Supplemental measures:

• Omega-3 fatty acid supplements show mixed evidence but may improve tear break-up time and meibum score 1, 3

Special Population Considerations

Preoperative patients:

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

Patients with advanced glaucoma:

• Advise against 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

Patients with rosacea, atopy, psoriasis, or eczema:

• These patients commonly have associated blepharitis and may require more aggressive management with oral antibiotics 3

Common Pitfalls to Avoid

• Do not expect cure or discontinue treatment once symptoms improve—this is a chronic condition requiring lifelong management 2, 1, 3
• Avoid prolonged continuous antibiotic use without rotation, which promotes resistance 2, 1
• Ensure patients have adequate manual dexterity and judgment to perform eyelid cleansing safely 2
• Treatment requires persistence and often a trial-and-error approach to find the optimal regimen 2, 1