eMedicine Specialties > Ophthalmology > Lid
Blepharitis, Adult: Treatment & Medication
Updated: Jul 30, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Medical Care
A systematic and long-term commitment to a program of eyelid margin hygiene is the basis of treatment of blepharitis. Clinicians must ensure that patients recognize that the management of blepharitis is a process, which must be carried out for prolonged periods of time. This understanding helps reduce "doctor shopping," a process in which a patient goes from physician to physician, seeking some panacea for this frustrating condition.4
- Many appropriate systems of eyelid hygiene exist, and all include variations of 3 essential steps.
- First, application of heat to warm the eyelid gland secretions and to promote evacuation and cleansing of the secretory passages is essential. Patients commonly are directed to use soaked warm compresses and to apply them to the lids repeatedly. Warm water in a washcloth, soaked gauze pads, or microwaved, soaked cloths can be used. Patients should be instructed to use extreme care and to avoid the use of excessive heat.
- Second, the eyelid margin is washed mechanically to remove adherent material, such as scurf, collarettes, and crusting, and to clean the gland orifices. This can be completed with a warm washcloth or with gauze pads. Water often is used, although some clinicians prefer that a few drops of baby shampoo be mixed in one bottle cap full of warm water to form a cleaning solution. Attention must be directed to gentle mechanical jostling or scrubbing of the eyelid margin itself, not the skin of the lids or of the bulbar conjunctival surface. Vigorous scrubbing is not necessary and may be harmful.
- Third, an antibiotic ointment is applied to the eyelid margin after it has been soaked and scrubbed. Commonly used agents include erythromycin or sulfacetamide ointments. Antibiotic-corticosteroid ointment combinations can be used for short courses, although their use is less appropriate for long-term management.
- Specific clinical situations may require additional treatment. Refractory cases of blepharitis often respond to oral antibiotic use. One- or two-month courses of tetracycline often are helpful in reducing symptoms in patients with more severe disease. Tetracycline is believed not only to reduce bacterial colonization but also to alter metabolism and reduce glandular dysfunction. The use of metronidazole is being studied.
- Tear film dysfunctions can prompt use of artificial tear solutions, tear ointments, and closure of the puncta. Associated conditions, such as herpes simplex, varicella-zoster, or staphylococcal skin disease, can require specific antimicrobial therapy based on culture. Seborrheic disease is often improved by the use of shampoos with selenium, although its use around the eyes is not recommended. Allergic dermatitis can respond to topical corticosteroid therapy.
- Conjunctivitis and keratitis can result as a complication of blepharitis and require additional treatment besides eyelid margin therapy. Antibiotic-corticosteroid solutions can greatly reduce inflammation and symptoms of conjunctivitis. Corneal infiltrates also can be treated with antibiotic-corticosteroid drops. Small marginal ulcers can be treated empirically, but larger, paracentral, or atypical ulcers should be scraped and specimens sent for diagnostic slides and for culture and sensitivity testing.
- Recurrent bouts of inflammation and scarring from blepharitis can promote eyelid positional disease. Trichiasis and lid notching can result in keratitis and severe symptoms. These conditions often are very refractory to simple management steps. Trichiasis is treated with epilation, destruction of the follicles via electric current, laser, or cryotherapy, or with surgical excision. Entropion or ectropion can develop and complicate the clinical situation and may require referral to an oculoplastics surgeon.
Surgical Care
Surgical care for blepharitis is needed only for complications such as chalazion formation, trichiasis, ectropion, entropion, or corneal disease.
Consultations
Patients with refractory acne rosacea may benefit from a consultation with a dermatologist.
Diet
Patients with poor nutrition may be at a higher risk for blepharitis.
Medication
Useful medications in the treatment of blepharitis may include topical antibiotics, topical corticosteroids, and oral antibiotics. Typical blepharitis may be treated with a hygiene regimen and topical antibiotic ointment. Use of combination corticosteroid and antibiotic ointment should not be long term but may prove useful in reduction of inflammation in difficult cases. Oral tetracyclines may be required for refractory cases. Also, a combination antibiotic and steroid drop may be required for associated corneal disease.5
Topical antibiotic ointments
Useful in targeting offending pathogens, usually Staphylococcus aureus (and possibly other Staphylococcus, Propionibacterium, Demodex, and Pityrosporum species, which chronically infect the lashes); the mechanism of action seems to be reduction of staphylococcal lipase production more than actual bacterial elimination.
Erythromycin ointment 0.5% (E-Mycin)
Erythromycin ointment is applied to lid margins with a clean vector, such as a cotton swab or a clean fingertip, after crusting and debris have been removed with gentle cleansing or scrubbing.
Adult
Apply a small amount (0.5-inch ribbon) topically to the outer lid 3-4 times qd
Pediatric
Not established
None reported
Documented hypersensitivity to erythromycin or ointment additives
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Do not use topical antibiotics to treat ocular infections that may become systemic; prolonged or repeated antibiotic therapy may result in bacterial or fungal overgrowth of nonsusceptible organisms and may lead to a secondary infection (take appropriate measures if superinfection occurs)
Topical antibiotic/corticosteroid suspension/ointment
Topical corticosteroids, combined with an antibiotic, may be useful in the short-term treatment of blepharitis to decrease inflammation and more quickly diminish symptoms. Long-term use is not recommended. An ointment may be used for blepharitis, while a drop may be needed if associated corneal disease develops.
Sulfacetamide sodium and prednisolone acetate (Blephamide)
Sulfacetamide is an antibiotic that, like erythromycin, has been shown to be effective against staphylococci. The combined corticosteroid is useful in decreasing inflammation and decreasing symptoms. Use of the 2 agents combined has been shown to increase patient compliance. Blephamide is available in an ophthalmic suspension and in an ointment, both containing the same concentrations of active ingredients (10% sulfacetamide/0.2% prednisolone).
Adult
Ointment: 0.5-inch ribbon topically to affected lid(s) 3-4 times qd and once or twice at night; discontinuation should be gradual
Drops: May be instilled 1 gtt 3-4 times qd; gradual discontinuation is necessary
Pediatric
Not established
Decreases effects of silver compounds and gentamicin
Documented hypersensitivity to any ingredients, sulfonamides, or corticosteroids; viral, mycobacterial, and fungal eye disease; glaucoma or ocular hypertension
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Use may cause glaucoma and posterior subcapsular cataract formation; rarely, fatalities have occurred due to severe reactions to sulfonamides, including Stevens-Johnson syndrome, toxic epidermal necrolysis, fulminant hepatic necrosis, agranulocytosis, aplastic anemia, or other blood dyscrasias; if inflammation or pain persists longer than 48 h or becomes aggravated, the patient should discontinue and consult a physician; consult a Physicians' Desk Reference or package insert for further details
Oral antibiotics
Staphylococcal blepharitis usually responds more quickly to combined use of topical and oral antibiotics, although a trial of topical antibiotics alone usually is indicated before oral antibiotics should be considered. Tetracyclines are the DOC.
Tetracycline (Sumycin)
Treats gram-positive and gram-negative organisms as well as mycoplasmal, chlamydial, and rickettsial infections. Inhibits bacterial protein synthesis by binding with 30S and possibly 50S ribosomal subunit(s). Metabolized by the liver and the kidneys. Usually not the DOC for most staphylococcal infections but has been shown to be effective in the treatment of refractory blepharitis, in which Staphylococcus aureus is the usual pathogen. Tetracyclines should not be taken with antacids or foods, but rather, they should be taken 1-2 h after meals.
Adult
1-2 g PO divided bid to qid, depending on severity, for 1-2 mo
Pediatric
Not established
Bioavailability decreases with antacids containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate; can decrease effects of oral contraceptives, causing breakthrough bleeding and increased risk of pregnancy; tetracyclines can increase hypoprothrombinemic effects of anticoagulants
Documented hypersensitivity; pregnant or breastfeeding women; renal or hepatic impairment
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Has been shown to cause yellow-gray-brown discoloration of the teeth if used during tooth development (last one half of pregnancy up to age 8 y); photosensitivity is common and avoidance of the sun is essential; may cause an increase in BUN and should be avoided in those with impaired renal function; has been linked to the development of pseudotumor cerebri; superinfection may occur; various adverse reactions may occur; refer to the Physicians' Desk Reference or package insert for more complete information
Doxycycline (Bio-Tab, Doryx, Vibramycin, Doxy)
Inhibits protein synthesis and thus bacterial growth by binding to 30S and possibly 50S ribosomal subunits of susceptible bacteria.
Adult
100-200 mg PO qd; some sources recommend using one half of initial dose during second month
Pediatric
Not established
Bioavailability decreases with antacids containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate; tetracyclines can increase hypoprothrombinemic effects of anticoagulants; tetracyclines can decrease effects of oral contraceptives, causing breakthrough bleeding and increased risk of pregnancy
Documented hypersensitivity; pregnant or breastfeeding women; renal or hepatic impairment
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Photosensitivity may occur with prolonged exposure to sunlight or tanning equipment; reduce dose in renal impairment; consider drug serum level determinations in prolonged therapy; tetracycline use during tooth development (last one half of pregnancy through age 8 y) can cause permanent discoloration of teeth; Fanconilike syndrome may occur with outdated tetracyclines
More on Blepharitis, Adult |
| Overview: Blepharitis, Adult |
| Differential Diagnoses & Workup: Blepharitis, Adult |
 Treatment & Medication: Blepharitis, Adult |
| Follow-up: Blepharitis, Adult |
| References |
| Further Reading |
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References
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Dhingra KK, Saroha V, Gupta P, Khurana N. Demodex-associated dermatologic conditions - A coincidence or an etiological correlate. Review with a report of a rare case of sebaceous adenoma. Pathol Res Pract. Jan 22 2009;[Medline].
Jackson WB. Blepharitis: current strategies for diagnosis and management. Can J Ophthalmol. Apr 2008;43(2):170-9. [Medline].
Luchs J. Efficacy of topical azithromycin ophthalmic solution 1% in the treatment of posterior blepharitis. Adv Ther. Sep 2008;25(9):858-70. [Medline].
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Diaz-Valle D, Benitez del Castillo JM, Fernandez Acenero MJ. Bilateral lid margin ulcers as the initial manifestation of Crohn disease. Am J Ophthalmol. Aug 2004;138(2):292-4. [Medline].
Fraunfelder FT, Roy FH, Steinemann TL. Current Ocular Therapy. 5th ed. 2000:72, 374, 378, 450.
Held KS. Blepharitis. In: Decision Making in Ophthalmology. 2nd ed. 2000:50-51.
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Further Reading
Related eMedicine topics
Papilloma, Eyelid
Basal Cell Carcinoma, Eyelid
Squamous Cell Carcinoma, Eyelid
Eyelid Coloboma
Eyelid Myokymia
Guidelines
Blepharitis
Clinical studies
Safety/Efficacy of Antibiotic Steroid Combination in Treatment of Blepharitis and/or Keratitis and/or Conjunctivitis (BRA-07-02)
Topical IL-1 for Treatment of Posterior Blepharitis
Keywords
adult blepharitis, seborrheic blepharitis, eyelid inflammation, inflammation of the eyelid, bacterial colonization of the eyelid, bacterial infection, anterior blepharitis, posterior blepharitis
