REVIEW

CURRENT
OPINION Medical management of blepharitis
Katherine Duncan and Bennie H. Jeng

Purpose of review
Blepharitis is one of the most common ocular pathologies encountered in the clinical setting. Despite its
prevalence, successful treatment is often difficult. The purpose of this review is to provide an update on the
medical management of blepharitis.
Recent findings
The available treatment options for blepharitis have expanded rapidly in recent years. Eyelid hygiene
remains the foundation of most treatment regimens, but the addition of topical and oral antibiotics, steroids,
and calcineurin inhibitors is showing promising results. Dietary considerations and interventional
procedures may also play a role in the future of blepharitis management.
Summary
Although a curative therapy for blepharitis is unlikely in the near future, several novel treatment options
may result in better control of this chronic condition.
Keywords
anterior blepharitis, meibomian gland dysfunction, posterior blepharitis

INTRODUCTION with Staphylococcus infection and seborrheic derma-

Blepharitis is a chronic inflammatory condition of
the eyelids and is typically classified into anterior
and posterior blepharitis [1,2]. It is among the most
common ocular conditions, affecting up to 47% of
patients seen in the clinical setting [1,3]. Although
usually mild and benign, severe cases can result in
permanent eyelid deformity and vision loss from
associated keratopathy. Despite its prevalence, treat-
ment has historically been difficult with no
uniformly successful therapies, making blepharitis
a chronic condition characterized by exacerbations
and remissions for the majority of patients.
ETIOLOGY
The etiology (the study of causes of disease) and
pathophysiology of blepharitis is complex and
poorly understood. It is likely multifactorial in
nature but has been associated with infectious con-
ditions, systemic diseases, and environmental fac-
tors. The different types of blepharitis (listed below)
have different proposed etiologies.
Anterior blepharitis
Anterior blepharitis describes inflammation of the
eyelid skin and eyelash follicles and may be accom-
panied by squamous debris or collarettes [1,2,4].
Anterior blepharitis has classically been associated
titis. Eyelid cultures from patients with blepharitis
grow significantly more Staphylococcus aureus when
compared with controls, whereas the rate of Staph-
ylococcus epidermidis is similar in both populations.
Despite this difference, less than half the total number
of patients diagnosed with staphylococcal blepharitis
have positive cultures [5]. The exact mechanism of
staphylococcal blepharitis has not been determined
and there are likely other contributing factors that
have not yet been identified [6]. Seborrheic dermatitis
is present in 95% of patients diagnosed with sebor-
rheic blepharitis [7]. Seborrheic blepharitis is often
associated with meibomian gland dysfunction in
addition to anterior blepharitis [4].
Posterior blepharitis
Posterior blepharitis describes inflammation of the
meibomian glands and their orifices and may be a
result of or cause of meibomian gland dysfunction
Department of Ophthalmology and Visual Sciences, University of Mary-
land School of Medicine, Baltimore, Maryland, USA
Correspondence to Bennie H. Jeng, MD, MS, Department of Ophthal-
mology and Visual Sciences, University of Maryland School of Medicine,
419 W. Redwood Street, Suite 470, Baltimore, MD 21201, USA.
Tel: +1 667 214 1232; e-mail: BJeng@som.umaryland.edu
Curr Opin Ophthalmol 2015, 26:289–294
DOI:10.1097/ICU.0000000000000164

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Corneal and external disorders
KEY POINTS
 Blepharitis remains a common ocular disease with no
established cure.
 Eyelid hygiene continues to play an important role in
the symptomatic management of blepharitis.
 Topical and oral macrolide therapy may be effective
because of its anti-inflammatory and antibiotic activity.
 Topical steroids may be used in conjunction with
antibiotics and eyelid hygiene for exacerbations but
should not be used chronically because of the risk of
elevated intraocular pressures.
 A staged algorithm of treatment beginning with eyelid
hygiene and dietary supplementation followed by
topical and then oral medications is recommended.
(MGD) [1,2,4]. MGD and posterior blepharitis are
often incorrectly used interchangeably. MGD refers
to a diffuse abnormality of the meibomian glands
resulting in duct obstruction, alteration of the tear
film and evaporative dry eye [1]. MGD is one cause
of posterior blepharitis but others include infectious
or allergic conjunctivitis, and rosacea [6]. The preva-
lence of rosacea among blepharitis patients has been
found to be as high as 44% [8].
Marginal blepharitis
Marginal blepharitis is a term used to describe the
coexistence of both anterior and posterior blepharitis.
As there is often significant overlap between anterior
and posterior blepharitis, many etiologies of blephar-
itis are not specific for one type of blepharitis over the
other. Demodex mites are intracutaneous parasites
that inhibit hair follicles and sebaceous glands. Demo-
dex infestation has been associated with both anterior
and posterior blepharitis [9]. Phthirus pubis (crab lice)
(a)
FIGURE 1. Color photographs showing plugging of the meibomian glands (a) and thickened meibomian secretions (b),
characteristic of posterior blepharitis. (Reproduced by courtesy of Todd P. Margolis, MD, PhD.)
290 www.co-ophthalmology.com
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is another, less common, parasitic infection of the lids
that has also been associated with blepharitis [10].
Patients who use Isotretinoin, a drug commonly used
to treat severe acne vulgaris, have been shown to
suffer from higher rates of blepharitis [11].
DIAGNOSIS
Clinical appearance
The diagnosis of blepharitis is almost always based
on the history and clinical exam. Anterior blephar-
itis is most commonly associated with oily eyelids,
matted lashes, collarettes, erythema, and edema of
the eyelid margin, poliosis, and eyelash loss and
misdirection. In more severe cases, eyelid ulceration
and scarring may be present. Posterior blepharitis
typically manifests as pouting or plugging of the
meibomian orifices, frothy tears, thickened and
reduced meibomian excretions, and thickening
and scalloping of the eyelid margin (Fig. 1) [2,4].
Rosacea is often characterized by telangiectatic
vessels at the eyelid margin and erythema, papules,
and pustules of the facial skin (Fig. 2) [6]. Cylindrical
scurf is often seen with Demodex-associated blephar-
itis. Individual mites can be seen on epilated lashes
under the microscope [9]. Phthirus pubis can be
identified on careful examination as translucent lice
and nits adhering to the eyelashes (Fig. 3) [10].
Alternative diagnoses should be considered in
patients with a clinical exam suggestive of blepharitis
who have been unresponsive to therapy. Eyelid car-
cinomas and discoid lupus erythematosus can appear
clinically similar to blepharitis in some cases. Crohn’s
disease may rarely present as ulcerative blepharitis [4].
Ancillary testing
There is no routinely used diagnostic test for ble-
pharitis, as most diagnoses are made by clinical
(b)
Volume 26  Number 4  July 2015

FIGURE 2. Color photograph showing telangiectatic vessels
at the eyelid margin suggestive of rosacea. (Reproduced by
courtesy of Todd P. Margolis, MD, PhD.)
appearance. Culturing the eyelid margins can
be considered in cases of refractory or severe ble-
pharitis [4]. Confocal microscopy is an emerging
noninvasive technique used to evaluate ocular dis-
ease on a cellular level. In recent studies, it has
been successfully used to assess and follow the
pathological changes occurring at the eyelid margin
in patients with blepharitis. Confocal microscopy
can identify periglandular inflammatory cells,
which are 10–30 times higher in patients with
blepharitis [12].
TREATMENT
Blepharitis is a chronic condition with no estab-
lished cure. There is a lack of consistent evidential
support in the literature for any of the numerous
therapies directed at blepharitis. Treatment may
differ depending on type of blepharitis, but there
is often considerable overlap in presentation, and
in treatment.
(a)
FIGURE 3. Color photographs showing a single louse at the central lid margin (a) and many translucent nits (eggs) adhering
to the eyelashes (b).
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Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Medical management of blepharitis Duncan and Jeng
Eyelid hygiene
Eyelid hygiene has been considered the mainstay of
blepharitis treatment for many years. Warm com-
presses are commonly recommended as a means of
melting meibomian lipids to improve secretion.
Olson and associates were able to objectively dem-
onstrate an 80% increase in the tear film lipid layer
thickness after applying warm compresses to the
eyelids for 5 min in patients with MGD [13]. Objec-
tive studies have determined the most efficacious
compress regimen to involve application of com-
presses heated to 45oC for at least 4 min with
replacement of the compress every 2 min to main-
tain the recommended temperature [14].
In addition to warm compresses, mechanical eye-
lid hygiene including eyelid scrubs and eyelid mas-
sage are commonly recommended initial steps in the
management of blepharitis. Weekly eyelid scrubs
with tea tree oil and daily eyelid scrubs with tea tree
shampoo have been shown to improve blepharitis in
patients with known Demodex infestation [15]. A
number of treatment options have been reported to
be successful for Phthiriasis palpebrarum, including 4%
pilocarpine gel and oral ivermectin; however, mech-
anical removal of lice and nits with forceps has shown
similar efficacy without the need for medical therapy
[16]. After review of 34 studies on the management of
chronic blepharitis, Lindsley et al. [6] determined that
warm compresses and mechanical eyelid hygiene
result in symptomatic relief for most patients, but
as expected, this does not cure blepharitis.
Pharmacologic treatment
Antibiotics
Although the pathogenesis is not completely under-
stood, bacterial imbalance at the eyelid margin is
thought to play a role in the development of blephar-
itis, and therefore antibiotics have been widely
evaluated and utilized in its treatment. Topical
(b)
www.co-ophthalmology.com 291
Corneal and external disorders
formulations of antibiotics have frequently been used
to deliver local therapy with limited risk for adverse
effects. Bacitracin and erythromycin ointments have
been used most commonly. Other topical agents
including fusidic acid, metronidazole, and fluoroqui-
nolones have shown some efficacy in the treatment of
blepharitis [2,17]. Macrolides have the advantage of
exhibiting anti-inflammatory and antibacterial
activity, making them an ideal treatment choice.
Erythromycin was the first macrolide antibiotic dis-
covered but because of extensive use, microbial resist-
ance may limit its efficacy [16]. Of 16 culture positive
patients with anterior blepharitis, one study found
that six of these patients showed antibiotic resistance
to erythromycin and ciprofloxacin [18].
Azithromycin, a second-generation macrolide,
has recently gained popularity because of its broad
spectrum of activity, potency (up to four times that
of erythromycin), anti-inflammatory properties,
excellent ocular tissue penetration, and prolonged
duration of activity. Azithromycin levels were found
to persist in the tear film and conjunctiva for 6 days
after the administration of a single drop of topical
azithromycin 1% [19]. Luchs et al. [20] found that
patients randomized to topical 1% azithromycin
and warm compresses showed significantly less mei-
bomian gland plugging, less eyelid margin eryth-
ema, improved meibomian gland secretion, and
patients reported greater symptom relief compared
with those who used warm compresses alone.
Another study evaluated treatment duration of 1
month versus 3 days of topical 1.5% azithromycin
and found that patients treated for 1 month had
significantly less eyelid edema/erythema and MGD
when evaluated at 3 months posttreatment [21].
Oral antibiotics with antimicrobial and anti-
inflammatory properties have been advocated for
refractory cases of blepharitis. Tetracyclines have
been used extensively in the treatment of rosacea
because of their anti-inflammatory properties. At
low doses, tetracyclines inhibit the inflammatory
process by reducing the release of pro-inflammatory
cytokines and the activity of matrix metalloprotei-
nases [16]. Treatment with oral minocycline 100 mg
daily for 3 months has been shown to significantly
decrease eyelid flora, especially S. aureus, in patients
with blepharitis [22]. Yoo et al. [23] found that
doxycycline 20 mg twice daily, a sub-antimicrobial
dose, was equally as effective as doxycycline 200 mg
twice daily at treating MGD. It is likely a combi-
nation of the antimicrobial and anti-inflammatory
properties of tetracyclines that make them effective
in cases of refractory blepharitis.
Recent studies have sought to evaluate the role of
oral azithromycin in the treatment of blepharitis,
given its ideal pharmacokinetic profile and efficacy
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in the topical form. A single 1 g dose of oral azithro-
mycin maintains antimicrobial levels for 14 days in
the conjunctiva [24]. The initial study of oral azithro-
mycin for posterior blepharitis showed significant
improvements in all symptoms and examination
findings evaluated with the exception of foreign
body sensation and eyelid swelling [25]. Oral azithro-
mycin’s efficacy was supported by a second study in
which 75% of patients with meibomitis treated with
1 g oral azithromycin/week reported symptomatic
&
improvement [26 ]. Although preliminary reports
are promising, azithromycin should be used with
caution and restricted to refractory cases of blephar-
itis, considering the small but significant increased
rate of cardiovascular death, which has been associ-
ated with its use [27]. Larger randomized trials are
needed to further evaluate the role of azithromycin in
the management of blepharitis.
Steroids
As a result of the infectious and inflammatory nature
of blepharitis, topical steroid use may be helpful to
control acute exacerbations, although long-term use
is associated with the risk of elevated intraocular
pressures and cataract formation. Hosseini et al.
randomized 417 patients with blepharoconjunctivi-
tis to treatment with either a combination of 1%
topical azithromycin and 0.1% topical dexametha-
sone, topical azithromycin alone, or topical dexa-
methasone alone. The study concluded that the
combination therapy was more effective than azi-
thromycin alone in improving blepharoconjunctivi-
tis signs and symptoms, and it was more effective
than dexamethasone alone in bacterial eradication
[28]. Another study compared loteprednol etabonate
0.5%/tobramycin 0.3% ophthalmic suspension to
dexamethasone 0.1%/tobramycin 0.3% ophthalmic
suspension and found that they had comparable
efficacy, but the dexamethasone 0.1%/tobramycin
0.3% ophthalmic suspension was associated with
twice as many intraocular pressure elevations of 5
mmHg or more [29]. Steroid use for blepharitis should
be limited to short-term use for acute exacerbations
and should be low potency when possible.
Calcineurin inhibitors
Calcineurin inhibitors are immunomodulatory
agents, which have been used in the treatment of
blepharitis because of their ability to reduce inflam-
mation without the adverse effects associated with
topical steroid use. Cyclosporine has been used to
treat a variety of ocular conditions, including dry
eye disease. Perry et al. randomized patients to treat-
ment with topical cyclosporine versus placebo and
found statistically significant reductions in eyelid
margin erythema, meibomian gland inclusions,
Volume 26  Number 4  July 2015

Signs and symptoms
of blepharitis
Anterior Posterior
blepharitis blepharitis
Warm compresses
and eyelid scrubs
No
Topical:
- Antibiotics ± low potency steroid
- Calcineurin inhibitors
Systemic:
- Antibiotics (macrolides, tetracyclines)
- Omega-3 fatty acid supplementation
FIGURE 4. A proposed algorithm for the medical management of blepharitis.
telangiectasia, and corneal staining at 3 months
[30]. In another study, patients with posterior
blepharitis randomized to treatment with topical
cyclosporine had greater improvement in Schirm-
er’s scores, tear break up time, meibomian gland
secretion quality, and patient symptoms when com-
pared with topical tobramycin/dexamethasone [31].
Pimecrolimus cream and tacrolimus ointment
to the eyelids have also been reported to be effica-
cious in the treatment of blepharoconjunctivitis,
but 6–12% of patients experience herpes simplex
&
virus reactivation while undergoing treatment [32 ].
Dietary supplements
Dietary supplementation has recently emerged as
a consideration in the treatment plan of patients
with blepharitis. Diet supplementation with omega-
3 fatty acids for 1 year has been shown to improve
patient symptoms and objective examination find-
ings in patients with MGD and blepharitis [33].
Interventional treatment
Various novel interventional therapies for blephar-
itis are currently in development. Maskin et al. have
developed a method of mechanically opening and
dilating obstructed meibomian gland orifices using
small stainless steel probes. Initial studies reported
that all 25 patients who underwent this procedure
reported symptomatic relief within 4 weeks [34].
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Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Medical management of blepharitis Duncan and Jeng
Marginal
blepharitis
Tea tree oil
Yes and
Demodex? shampoo
No
Phthiriasis
Yes Mechanical
palpebrarum?
removal of
lice and
nits
Other interventional procedures including thermal
pulsation and intense pulsed light utilizing heat to
improve lipid mobilization. Thermal pulsation
involves a device that delivers 12 min of heat and
pulsatile pressure to the meibomian glands in an
effort to alleviate obstruction [35]. Intense pulsed
light therapy has been used to treat many dermato-
logic conditions and has been shown to improve
&
meibomian gland secretion [36 ]. Although initial
data are encouraging, these procedures are currently
in the early stages of development and the equip-
ment necessary for these therapies is expensive at
the time of this writing.
CONCLUSIONS
Blepharitis is one of the most commonly encountered
ocular pathologies in the clinical setting. Despite its
prevalence, there are currently no medications
approved by the United States Food and Drug Admin-
istration for the indication of blepharitis. Several
different treatment modalities have been proposed
and evaluated, many showing significant improve-
ment in patient signs and symptoms. A staged algor-
ithm of treatment is the ideal approach to blepharitis
beginning with eyelid hygiene, followed by topical
and then oral medications (Fig. 4). Both patient and
clinician need to understand the complexity and
chronicity of the condition and the multifaceted
approach that is often required to control it. Although
there is currently no established cure for blepharitis,
www.co-ophthalmology.com 293
Corneal and external disorders
our understanding of this condition and its treatment
has rapidly expanded in recent years and will hope-
fully continue to do so in the near future.
Acknowledgements
None.
Financial support and sponsorship
None.
Conflicts of interest
There are no conflicts of interest.
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