Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

no visual impairment

1st line – eyelid hygiene measures

Back
ACUTE
|
no visual impairment
1st line – 

eyelid hygiene measures

Explain that cure is not usually possible, but that symptoms can be lessened with consistent treatment.[1]​ Eyelid hygiene measures are required for the initial and maintenance treatment of blepharitis.[1][37]​​

Warm compresses are applied to the eyelid for 5-10 minutes twice daily, aiming to aid expression by raising the temperature above the melting point of meibum. However, an expert panel deemed that this approach may be of limited value in patients with Demodex blepharitis.[36]

Eyelid scrubs, used to clear away the scales on lashes, improve both patient-reported symptoms and clinical findings.[38] Eyelid massage is thought to help express meibomian gland secretions and improve capping of the gland orifices.

In-office procedures to unclog the meibomian glands using thermal pulsation or mechanical means are available, but they have not been assessed in randomised controlled trials.

Consider – treatment of underlying disease

Back
ACUTE
|
no visual impairment
Consider – 

treatment of underlying disease

Additional treatment recommended for SOME patients in selected patient group

Not uncommonly, symptoms may be secondary to another condition (e.g., eczema, rosacea). Treating any underlying disease is essential for successful blepharitis therapy.

Consider – omega-3 fatty acids

Back
ACUTE
|
no visual impairment
Consider – 

omega-3 fatty acids

Additional treatment recommended for SOME patients in selected patient group

Omega-3 dietary supplementation may benefit some patients with blepharitis, but evidence is conflicting.[1]

One study found improvement in tear film break-up time, dry eye symptoms, and meibum score after 1 year of omega-3 fatty acid supplementation, but a subsequent trial found no significant improvement compared with placebo.[39][40]

Primary options

omega-3-acid ethyl esters: consult product literature for guidance on dose

Consider – artificial tears or topical ophthalmic ciclosporin

Back
ACUTE
|
no visual impairment
Consider – 

artificial tears or topical ophthalmic ciclosporin

Additional treatment recommended for SOME patients in selected patient group

​Assess and treat associated dry eye syndrome with either artificial tears or topical ophthalmic ciclosporin on an 'as required' basis.[41] Various artificial tear formulations are available over-the-counter.

Compared with artificial tears, ciclosporin improves ocular symptoms, lid margin vascular injection, tarsal telangiectasis, and fluorescein staining while decreasing meibomian gland inclusions.[42] However, ciclosporin has shown mixed results in other studies.[43]

One Cochrane review found that there is no high quality evidence to support the efficacy and safety of topical treatments for blepharitis in children (e.g., corticosteroids and antibiotics in combination for children with blepharokeratoconjunctivitis).[44]

Refer patients with more severe blepharitis to an ophthalmologist for additional measures (e.g., punctal plugs or cauterisation).

Primary options

ciclosporin ophthalmic: (0.1% emulsion) 1 drop into the affected eye(s) once daily

Consider – topical antibiotic therapy

Back
ACUTE
|
no visual impairment
|
unresponsive to initial therapies
Consider – 

topical antibiotic therapy

Additional treatment recommended for SOME patients in selected patient group

Patients with blepharitis unresponsive to initial therapies may benefit from treatment with topical antibiotics.[1][37]​ Erythromycin or bacitracin ointment are the first-line options.[45]

Some specialists recommend the use of azithromycin ophthalmic solution as a second-line treatment option for meibomian gland dysfunction. Although data conflict on the use of azithromycin for this purpose, one systematic review and meta-analysis concluded that topical therapy improved symptoms, signs, and tear-film stabilisation, at least in the short-term.[43][46]

Topical treatments are discontinued after a few weeks, once the acute symptoms resolve, but some patients may require long-term use.

Cultures can help if blepharitis remains unresponsive.

Topical ophthalmic antibiotics may be available in proprietary combination formulations with a corticosteroid.

Primary options

bacitracin ophthalmic: (500 units/g) apply to affected inner lower eyelid(s) once daily at night for 4-6 weeks

OR

erythromycin ophthalmic: (0.5%) apply to affected inner lower eyelid(s) once daily at night for 4-6 weeks

Secondary options

azithromycin ophthalmic: (1%) 1 drop into the affected eye(s) daily for 2-4 weeks

Consider – topical antiparasitic therapy

Back
ACUTE
|
no visual impairment
|
unresponsive to initial therapies
Consider – 

topical antiparasitic therapy

Additional treatment recommended for SOME patients in selected patient group

A Delphi panel (Demodex Expert Panel on Treatment and Eyelid Health) concluded that collarettes may be considered pathognomonic for Demodex blepharitis and that patients with >10 collarettes should be treated, even in the absence of symptoms.[48]

Tea tree oil or metronidazole lid scrubs may be used for disease management.[1][49][50] Use low-concentration tea tree oil to avoid risk of damage to the corneal epithelium.[1][51]​​

Delphi methodology failed to establish a consensus regarding the best treatment for Demodex blepharitis, but determined that heat, including warm compresses, is not generally useful.[36]

Clinical trials, published subsequent to the Delphi panel, have found that topical lotilaner solution applied for 6 weeks significantly reduces collarettes, is associated with increased mite eradication, and reduces eyelid erythema compared with a vehicle control.[1][52][53]​​​​[54]

Primary options

metronidazole topical: (0.75% or 1%) apply to the affected eyelid(s) once daily

OR

lotilaner ophthalmic: (0.25%) 1 drop into the affected eye(s) twice daily for 6 weeks

Consider – topical corticosteroid therapy

Back
ACUTE
|
no visual impairment
|
unresponsive to initial therapies
Consider – 

topical corticosteroid therapy

Additional treatment recommended for SOME patients in selected patient group

In the acute inflammatory phase, especially with marginal keratitis or corneal phlyctenules, consider a short course of a topical ophthalmic corticosteroid.

Topical corticosteroids may prevent recurrent corneal erosions associated with ocular rosacea when given with oral doxycycline.[47]​

Taper therapy after symptoms resolve and avoid long-term corticosteroid use, where possible, due to the risks of cataract, superinfection, and glaucoma.

Topical ophthalmic corticosteroids may be available in proprietary combination formulations with an antibiotic.

Primary options

fluorometholone ophthalmic: (0.1%) 1 drop into the affected eye(s) four times daily for 7-14 days, then either discontinue or slowly taper over 3-4 weeks

OR

loteprednol ophthalmic: (0.5%) 1 drop into the affected eye(s) four times daily for 7-14 days, then either discontinue or slowly taper over 3-4 weeks

OR

prednisolone ophthalmic: (1%) 1 drop into the affected eye(s) four times daily for 7-14 days, then either discontinue or slowly taper over 3-4 weeks

Consider – oral antibiotic therapy

Back
ACUTE
|
no visual impairment
|
unresponsive to initial and topical therapies
Consider – 

oral antibiotic therapy

Additional treatment recommended for SOME patients in selected patient group

Guidelines suggest that patients with meibomian gland dysfunction with chronic symptoms and signs (not adequately controlled by eyelid cleansing or meibomian gland expression) may benefit from the addition of an oral antibiotic (typically a tetracycline or a macrolide) to existing therapy.[1][37] However, one 2021 Cochrane review found insufficient evidence to draw meaningful conclusions on the use of oral antibiotics for chronic blepharitis, and suggested that further research is needed in this area.[55]​​

Tetracyclines are known to cause hepatotoxicity and haemolytic anaemia, and they should not be used in pregnant or lactating women due to the risk of tooth enamel abnormalities in the baby.[5][56]

Oral erythromycin or azithromycin (macrolide antibiotics) can be considered alternatives for women of childbearing age, but care should still be taken with oral azithromycin due to its potential to trigger irregular heart rhythms.[1]

Tetracyclines and macrolides are effective in treating acne rosacea, which is frequently associated with posterior blepharitis and should be treated concomitantly.[1]​​

Primary options

doxycycline: 50-100 mg orally twice daily for 2-3 months, followed by 50-100 mg once daily

OR

tetracycline: 250-500 mg orally twice daily for 2-3 months, followed by 250-500 mg once daily

OR

minocycline: 50-100 mg orally twice daily for 2-3 months, followed by 50-100 mg once daily

Secondary options

erythromycin base: 250-500 mg orally twice daily for 2-3 months, followed by 250-500 mg once daily

OR

azithromycin: consult specialist for guidance on dose

Consider – ophthalmology referral

Back
ACUTE
|
no visual impairment
|
refractory or atypical disease
Consider – 

ophthalmology referral

Additional treatment recommended for SOME patients in selected patient group

Referral to appropriate healthcare professionals may be necessary depending on the presentation.[1]

Atypical, unilateral, or non-responsive eyelid margin inflammation (e.g., loss of eyelashes, extensive scarring) requires the exclusion of an eyelid tumour or immune-mediated disease.[1]​​

visual impairment secondary to corneal involvement

1st line – ophthalmology referral

Back
ACUTE
|
visual impairment secondary to corneal involvement
1st line – 

ophthalmology referral

Referral to appropriate healthcare professionals may be necessary depending on the presentation.[1]​ The American Academy of Ophthalmology supports the prompt and appropriate referral of individuals to an ophthalmologist when they present with any visual impairment, including that due to inflammation of the lids or conjunctiva, with or without discharge.[57]

Corneal ulceration and perforation requires management with aggressive antibiotic therapy, glue, or surgery. Atypical, unilateral, or non-responsive eyelid margin inflammation (e.g., loss of eyelashes, extensive scarring) requires the exclusion of an eyelid tumour or immune-mediated disease.[1]​​​ 

Plus – eyelid hygiene measures

Back
ACUTE
|
visual impairment secondary to corneal involvement
Plus – 

eyelid hygiene measures

Treatment recommended for ALL patients in selected patient group

Explain that cure is not usually possible, but that symptoms can be lessened with consistent treatment.[1] Eyelid hygiene measures are required for the initial and maintenance treatment of blepharitis.[1][37]​​

Warm compresses are applied to the eyelid for 5-10 minutes twice daily, aiming to aid expression by raising the temperature above the melting point of meibum. However, an expert panel deemed that this approach may be of limited value in patients with Demodex blepharitis.[36]

Eyelid scrubs, used to clear away the scales on lashes, improve both patient-reported symptoms and clinical findings.[38] Eyelid massage is thought to help express meibomian gland secretions and improve capping of the gland orifices.

In-office procedures to unclog the meibomian glands using thermal pulsation or mechanical means are available, but they have not been assessed in randomised controlled trials.

Plus – oral antibiotic therapy

Back
ACUTE
|
visual impairment secondary to corneal involvement
Plus – 

oral antibiotic therapy

Treatment recommended for ALL patients in selected patient group

Chronic suppressive oral antibiotics are indicated in patients with visual impairment. Tetracyclines are the preferred antibiotics.​

Tetracyclines are known to cause hepatotoxicity and haemolytic anaemia, and they should not be used in pregnant or lactating women due to the risk of tooth enamel abnormalities in the baby.[5][56]​​​

Oral erythromycin or azithromycin (macrolide antibiotics) can be considered alternatives for women of childbearing age, but care should still be taken with oral azithromycin due to its potential to trigger irregular heart rhythms.[1]

Tetracyclines and macrolides are effective in treating acne rosacea, which is frequently associated with posterior blepharitis and should be treated concomitantly.[1][37]

Primary options

doxycycline: 50-100 mg orally twice daily for 2-3 months, followed by 50-100 mg once daily

OR

tetracycline: 250-500 mg orally twice daily for 2-3 months, followed by 250-500 mg once daily

OR

minocycline: 50-100 mg orally twice daily for 2-3 months, followed by 50-100 mg once daily

Secondary options

erythromycin base: 250-500 mg orally twice daily for 2-3 months, followed by 250-500 mg once daily

OR

azithromycin: consult specialist for guidance on dose

Consider – topical antiparasitic therapy

Back
ACUTE
|
visual impairment secondary to corneal involvement
Consider – 

topical antiparasitic therapy

Additional treatment recommended for SOME patients in selected patient group

A Delphi panel (Demodex Expert Panel on Treatment and Eyelid Health) concluded that collarettes may be considered pathognomonic for Demodex blepharitis and that patients with >10 collarettes should be treated, even in the absence of symptoms.[48]

Tea tree oil or metronidazole lid scrubs may be used for disease management.[1]​​​​[49]​​​​​​​[50] Use low-concentration tea tree oil to avoid risk of damage to the corneal epithelium.[1][51]​​

Clinical trials, published subsequent to the Delphi panel, have found that topical lotilaner solution applied for 6 weeks significantly reduces collarettes, is associated with increased mite eradication, and reduces eyelid erythema compared with a vehicle control.[1][52][53]​​​​[54]​

Primary options

metronidazole topical: (0.75% or 1%) apply to the affected eyelid(s) once daily

OR

lotilaner ophthalmic: (0.25%) 1 drop into the affected eye(s) twice daily for 6 weeks

Consider – topical corticosteroid therapy

Back
ACUTE
|
visual impairment secondary to corneal involvement
Consider – 

topical corticosteroid therapy

Additional treatment recommended for SOME patients in selected patient group

Corneal changes such as vascularisation and scarring could benefit from a short course of topical corticosteroids.

Taper therapy after symptoms resolve and avoid long-term corticosteroid use, where possible, due to the risks of cataract, superinfection, and glaucoma.

Topical ophthalmic corticosteroids may be available in proprietary combination formulations with an antibiotic.

Primary options

fluorometholone ophthalmic: (0.1%) 1 drop into the affected eye(s) four times daily for 7-14 days, then either discontinue or slowly taper over 3-4 weeks

OR

loteprednol ophthalmic: (0.5%) 1 drop into the affected eye(s) four times daily for 7-14 days, then either discontinue or slowly taper over 3-4 weeks

OR

prednisolone ophthalmic: (1%) 1 drop into the affected eye(s) four times daily for 7-14 days, then either discontinue or slowly taper over 3-4 weeks

Consider – omega-3 fatty acids

Back
ACUTE
|
visual impairment secondary to corneal involvement
Consider – 

omega-3 fatty acids

Additional treatment recommended for SOME patients in selected patient group

Omega-3 dietary supplementation may benefit some patients with blepharitis, but evidence is conflicting.[1] One study found improvement in tear film break-up time, dry eye symptoms, and meibum score after 1 year of omega-3 fatty acid supplementation, but a subsequent trial found no significant improvement compared with placebo.[39][40]

Primary options

omega-3-acid ethyl esters: consult product literature for guidance on dose

Consider – artificial tears

Back
ACUTE
|
visual impairment secondary to corneal involvement
Consider – 

artificial tears

Additional treatment recommended for SOME patients in selected patient group

Assess and treat associated dry eye syndrome with artificial tears on an 'as required' basis.[41]​ Various artificial tear formulations are available over-the-counter.

Refer patients with more severe blepharitis to an ophthalmologist for additional measures (e.g., punctal plugs or cauterisation).

Consider – topical ophthalmic ciclosporin

Back
ACUTE
|
visual impairment secondary to corneal involvement
Consider – 

topical ophthalmic ciclosporin

Additional treatment recommended for SOME patients in selected patient group

In patients with corneal inflammation not responding to oral antibiotics or topical corticosteroids, topical ophthalmic ciclosporin can reduce meibomian gland dysfunction.[42] Compared with artificial tears, ciclosporin improves ocular symptoms, lid margin vascular injection, tarsal telangiectasis, and fluorescein staining while decreasing meibomian gland inclusions.[42] However, it has shown mixed results in other studies.[43]

Primary options

ciclosporin ophthalmic: (0.1% emulsion) 1 drop into the affected eye(s) once daily

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Choose a patient group to see our recommendations

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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