Treating Blepharitis

In the last clinical pearl, we focused on diagnosis and differentiating the type of blepharitis. With that in mind, it’s time to customize your treatment.

The three most common forms of blepharitis are staphylococcal, demodex, and seborrheic. Each has a unique presentation and a specific treatment approach.

The presence of collarettes indicates demodex blepharitis. Treatments that have been shown to work include tea tree oil (TTO), Manuka honey, blepharoexfoliation, intense pulsed light (IPL), and low-level light therapy (LLLT). Although none of these treatments completely eradicate demodex, mainly because it is a common pathogen within normal flora, they may decrease the number of microorganisms.
• TTO comes in low and high concentrations. High concentrations (around 50%) can be very toxic and damaging to the meibomian glands. It’s possible that isolating the active ingredient, Terpinen-4-ol, makes it less toxic although long-term studies are needed to examine the effects on the meibomian glands. In my experience, lower doses don’t work for significant demodex infestations but may maintain improvements after in-office treatments.
• LLLT involving a blue-light mask followed by a red-light mask has shown significant effects on demodex blepharitis.
• Blepharoexfoliation with a BlephEx device effectively removes the collarettes and patho-gens, but like LLLT, must be repeated regularly.
There is an exciting therapeutic in development that may eradicate the mites but it’s a couple years away from a potential FDA approval. So for now, consider an in-office treatment followed by lid scrubs with the active ingredient in TTO in them, and expect to retreat every three to six months. These treatments can cause dry eye flareups so consider a short-term topical corticosteroid such as Eyesuvis for two weeks after treatment.

Staphylococcal blepharitis patients typically complain about mattering and discharge. The mattering can be found throughout the lashes.
• The best treatments for this condition include antibiotics or antibiotic/steroid combination agents, and lid hygiene products including hypochlorous acid (HOCl) cleansers and surfactant cleansers. I tend to use the HOCl cleansers in more advanced cases of staphylococcal blepharitis, and the surfactant cleaners in milder forms or for long-term maintenance.
• Hydrating compresses will also help soften the debris and discharge.
• In-office blepharoexfoliation works well to remove biofilm, and the LLLT procedure can also kill the bacteria. I typically involve blepharoexfoliation in addition to LLLT in most cases of blepharitis. TTO-based cleansers would not be recommended for staphylococcal blepharitis just as antibiotics wouldn’t be recommended for demodex blepharitis.

Seborrheic blepharitis appears as greasy scales on the eyelid itself, although flakes can also accumulate in the lashes.
• This is more of a dermatological condition, so dermatological creams such as triamcinolone 0.1% QD work well. These should only be used for up to three weeks. Long-term use of steroid creams has been associated with discoloration of the skin and even eyelid thinning.
• A long-term surfactant cleanser such as Lid Scrub Plus (OCuSOFT) seems to work well for this patient population.