Medication Summary
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 tetracycline class antibiotics may be required for refractory cases. Also, a combination antibiotic and steroid drop may be required for associated corneal disease. [11]
Ivermectin is a broad-spectrum antiparasitic drug used mainly to treat strongyloidiasis and onchocerciasis, although strong evidence upholds its off-label use against some arthropods. For patients with refractory blepharitis, ivermectin has been found to lessen the number of Demodex folliculorum found in the lashes.
In a noncomparative, interventional case series, researchers examined 24 eyes of 12 patients with refractory posterior blepharitis with the presence of D folliculorum in lash samples. [12] Patients were instructed to take 1 dose of oral ivermectin (200 ug/kg) and to repeat the treatment after 7 days. The researchers obtained tear meniscus height, Schirmer test results, noninvasive tear film break-up time, corneal fluorescein and rose bengal staining scores, and quantification of the absolute number of D folliculorum found in lashes from all patients 1 day before and 28 days after the 2-dose treatment.
A significant reduction was observed in the absolute number of D folliculorum found in the lashes after the treatment with oral ivermectin. Average values of Schirmer test results and tear film break-up time improved substantially after the treatment of oral ivermectin. The authors observed no significant improvement in average lacrimal meniscus height or value of corneal fluorescein and rose bengal staining after treatment with oral ivermectin. [12]
Lotilaner ophthalmic solution (Xdemvy) was approved by the FDA for treatment of Demodex blepharitis in July 2023. Lotilaner is a gamma-aminobutyric acid (GABA)-gated chloride channel inhibitor selective for mites. Inhibition of these GABA chloride channels causes a paralytic action in the target organism, leading to its death. [1, 10]
Topical antibiotic ointments
Class Summary
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 ophthalmic (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.
Bacitracin ophthalmic (Bacitracin Ophthalmic Ointment)
Bacitracin ointment is also 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.
Topical antibiotic/corticosteroid suspension/ointment
Class Summary
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).
Oral antibiotics
Class Summary
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.
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.
Anthelminthics
Class Summary
For patients with blepharitis caused by Demodex dolliculorum, ivermectin has been used off-label to lessen the number of Demodex folliculorum found in the lashes. Lotilaner ophthalmic has been approved by the FDA for treatment of Demodex blepharitis.
Ivermectin (Stromectol)
Binds selectively with glutamate-gated chloride ion channels in invertebrate nerve and muscle cells, causing cell death. Off-label use has been described for blepharitis associated with Demodex folliculorum.
Lotilaner ophthalmic (Xdemvy)
Gamma-aminobutyric acid (GABA)-gated chloride channel inhibitor selective for mites. Inhibition of these GABA chloride channels causes a paralytic action in the target organism, leading to its death. It is indicated for adults for treatment of Demodex blepharitis.
Dermatology, Herbals
Tea tree oil (Australian tea tree oil, Cymeme, Melaleuca alternifolia)
Tea tree oil provides a direct ant-parasitic effect upon D folliculorum. Tea tree oil, the essential oil derived from the native plant Melaleuca alternifolia, is characterized by 15 major components. Scientific studies have shown that 4-Terpineol, or Terpinen-4-ol (T4O), is the most important ingredient in tea tree oil. Tea tree oil is available commercially and from numerous natural-remedy companies. The active ingredient is available through BioTissue (Cliradex).
