Blepharitis

Introduction

Blepharitis is an inflammatory condition that affects the eye lid margins. The edges of the eyelids become red and swollen¹. It is a chronic condition which means that symptoms will reoccur if they are not managed. It may occur intermittently, and it is usually bilateral (meaning it affects both eyes).

Blepharitis is often used to refer specifically to ‘anterior blepharitis’, affecting the portion of the eyelid in front of the mucocutaneous junction. Posterior forms (affecting the portion behind the mucocutaneous junction), are typically identified according to their underlying cause, such as meibomian gland dysfunction (MGD)². TFOS DEWS III classifies anterior blepharitis as “inflammation of the lid margin anterior to the grey line and concentrated around the eyelashes”³.

Both anterior and posterior blepharitis can coexist and have links to dry eye disease sharing similar clinical features². It is important to remember that there is considerable overlap between anterior and posterior blepharitis (MGD).

The focus of the rest of this article will be on anterior blepharitis.

Blepharitis is the most common reason for same day cancellation of elective cataract surgery⁴. In research it has been linked with post operative endophthalmitis in cataract surgery where it was reported that the genetic makeup of organisms from the vitreous matched those recovered from the patient’s eyelids⁵.

Anterior blepharitis primarily impacts the base of the eyelashes, targeting the eyelash follicles and the surrounding eyelid skin. In cases where the eyelid skin itself becomes inflamed, the term blepharo-dermatitis is used to describe this particular presentation.

The pathophysiology involves the accumulation of various substances, such as debris, bacteria, mites, or oils, along the eyelid margin. This build-up leads to irritation of the delicate skin of the eyelids and disrupts normal eyelid function, perpetuating the chronic nature of the condition.

It may present with:

Crusting or flakes around lashes
Red, irritated lid margins
Itching, burning, or foreign‑body sensation
Ocular surface discomfort and dry eye symptoms

Anterior blepharitis includes three key subtypes:

Staphylococcal (bacterial)
Seborrhoeic (oily imbalance – skin related)
Demodex (mite‑related)

Each has different aetiological drivers (underlying causes), which is why identification matters.

Staphylococcal/Bacterial – this is caused by bacteria, normally staphylococcal by either

1) direct infection

2) reaction to staphylococcal exotoxins or

3) allergic response to staphylococcal antigens causing hard crusting on the eyelashes.

It is less common than seborrhoeic.

Seborrhoeic – this is a disorder of the ciliary sebaceous glands of Zeis which is associated with dandruff leading to waxy scales on the eyelashes.

Demodex infestation has also been found to be associated with blepharitis⁶. (Demodex Blepharitis)

Demodex are microscopic (ectoparasite) mites that live on the surface of the human body. Two types are thought to be specific to humans, Demodex folliculorum (DF) which is longer and more commonly localised to the face and Demodex brevis (DB) which are shorter and more commonly found on the neck and chest. DF are found in eyelash follicles and DB burrow deep into sebaceous and meibomian glands.

Demodex mites are also present in healthy eye lids without signs of blepharitis⁷.

Reports suggest that demodex act as carriers of bacteria such as staphylococcus⁷ and that the infestation and waste of the mites causes blockage of the follicles and glands and/or an inflammatory response². The number of demodex mites is believed to increase with age, and over 50% of patients with demodex will have signs of blepharitis⁷. Treatment is needed when it becomes necessary to reduce the quantity of DB and DF and this has been shown to improve patient symptoms and ocular surface health⁷.

Clinical Evaluation

Risk Factors for Blepharitis

Seborrheic dermatitis
Infections
Rosacea
Allergies
Demodex
Dry eyes
Long-term contact lens wear
Cosmetics

Staphylococcal (Bacterial) Blepharitis⁸

Cause

Overgrowth of Staphylococcus bacteria
Reaction to toxins or antigens produced by the bacteria
Chronic bacterial colonisation and biofilm formation

Signs

Hard crusting/scales at lash base (“collarettes”)
Lash loss (madarosis) or misdirected lashes
Marked lid margin redness
Telangiectasia
Conjunctival redness

Symptoms

Burning
Irritation
Foreign body sensation
Red rim around the eyes
Ocular discomfort

Seborrhoeic Blepharitis⁹

Cause

Linked to seborrhoeic dermatitis
Dysfunction of sebaceous glands of Zeis
Excess oily secretions and skin flaking

Signs

Oily/greasy deposits on lash base
Shiny or oily eyelid margins
Flaky skin on eyebrows/scalp/face
Mild erythema and inflammation

Symptoms

Tearing
Ocular irritation
Eyelids sticking
Uncomfortable greasy feeling

Demodex Blepharitis¹⁰

Cause

Infestation by Demodex mites
- D. folliculorum – lash follicles
- D. brevis – meibomian glands
Mites carry bacteria and trigger inflammation
Creates cylindrical collarettes (pathognomonic)

Signs

Crusting with sleeveless clear debris encasing lashes
Red, irritated lid margins
Collarettes visible with magnification
Associated with rosacea

Symptoms

Itching (very prominent)
Irritation
Discomfort around eyelashes
Persistent/stubborn inflammation

Varying degrees of ocular discomfort and or symptoms are reported but patients may also be asymptomatic.

Staphylococcal (Bacterial) Blepharitis

Staphylococcal (Bacterial) Blepharitis

Seborrhoeic Blepharitis

Seborrhoeic Blepharitis

Demodex Blepharitis

Demodex Blepharitis

Differences between common types of anterior blepharitis

	Staphylococcal Blepharitis	Seborrhoeic blepharitis	Demodex blepharitis
Lashes	Lash crusting (scales at base of lashes)	Oily/greasy deposits on lid margins and around lash bases	Crusting of lashes with a cylindrical sleeve around the base of the lash extending along the lash shaft
	Loss of lashes (madarosis)	Lash loss rare	Lash loss can occur
	Misdirection of lashes	–	–
Lid margin	Lid margin redness	Lid margin redness	Lid margin redness
	Eventual scarring and thickening of lid margin	Flaky skin in eyebrows	Mites under high magnification may be visible
	Telangiectasia	–	–
Inflammation	Significant inflammation on lid margins	Less inflammation on lid margins	Minimal inflammation on lid margins
Conjunctiva	Conjunctival redness	Conjunctival redness	–
Age of patient	Typically seen in younger patients	Tends to be in older patients	Prevalence increases with age
Skin signs	Skin is usually clear	Associated seborrhoeic dermatitis – flaky red skin	Rosacea association – red skin, telangiectasia papules and pustules

Investigations

Full anterior segment examination to exclude any other potential lid pathology
Consider appearance of lid crusting to aid differential diagnosis
Meibomian gland assessment (some practitioners find it useful to express the glands to gauge the quality and quantity of the secretions)

Management & Advice

The management of blepharitis depends on the type and severity of blepharitis¹¹. The key to treating most types of blepharitis is keeping the lids clean and free of crusts.

The TFOS DEWS III Management and Therapy Report (2025)¹⁶ stresses that blepharitis and eyelid related dry eye must be managed using individualised, evidence based, stepwise care. Blepharitis is chronic, and long-term control depends on addressing the true source of inflammation.

Understanding the driver allows clinicians to choose treatments patients can tolerate and maintain consistently.

Non-Pharmacological

Lid & lash cleansing: On going lid hygiene is essential for chronic eyelid conditions and tailoring frequency and specific cleansers helps maintain adherence and symptom relief
- There are a variety of lid cleansing products available to clean the crusting and debris from the lid margins and lash follicles. These products have been designed specifically for the delicate eye area. Traditionally diluted baby shampoo has been recommended for lid hygiene, but it is now known that baby shampoo can cause irritation and inflammation of the ocular surface along with adding to tear film instability¹².

DEWS III highlights the need for individualised treatment algorithms — meaning the correct therapy depends on why the blepharitis is happening.

Bacterial / Staphylococcal: benefits from antibacterial cleansing and debris removal
Seborrhoeic: benefits from effective oil lifting cleansers
Demodex: benefits from targeted anti-mite treatment

Hypochlorous acid (HOCL)
- Newer management strategies for anterior blepharitis include the use of hypochlorous acid (HOCl) as an adjunct to traditional eyelid hygiene. HOCl, typically formulated at 0.01%, is applied via eyelid wipes or atomization and has demonstrated efficacy in reducing lid margin redness, abnormalities, and improving meibum expressibility and quality, with a favourable safety profile and high patient tolerability¹³. HOCl acts as a broad-spectrum antimicrobial, significantly reducing staphylococcal load on periocular skin without altering microbial diversity.
Lid warming can be used prior to cleansing to soften and loosen any crusting on the lashes and may be particularly beneficial if the crusting is marked. It will also be beneficial for patients with MGD to soften thickened meibum. Commercially available warm compresses are often used for this purpose.
Hydration/Lubrication: As dry eye is commonly present as a consequence of blepharitis patients are often recommended to include an eye lubricant as part of the management of their blepharitis. Lubricants should be instilled after the lid warming and cleansing.

Newer in practice treatment options for anterior blepharitis include microblepharoexfoliation and low-level light therapies.

Microblepharoexfoliation¹⁴ is a professional in-office procedure that mechanically removes debris, biofilm, and scurf from the eyelid margin using a rotating brush or similar device. This approach is particularly useful for patients with recalcitrant anterior blepharitis and has shown benefit in reducing symptoms and improving eyelid margin health, especially in cases associated with Demodex infestation.

Low level light therapy (LLLT)¹⁵ using blue and red wavelengths have been suggested as adjunct treatments for managing recalcitrant blepharitis, particularly in cases associated with Demodex infestations. The mechanism is thought to involve the antimicrobial and anti-inflammatory effects of blue light, which targets Demodex and associated bacteria, while red light promotes tissue repair and reduces inflammation.

These modalities are typically reserved for patients with persistent or refractory blepharitis who do not respond to conventional lid hygiene and topical therapies.

Pharmacological¹¹

For more persistent or difficult to treat cases pharmacological options that may be considered include:

Topical antibiotics or topical antibiotic steroid combinations that can be applied to the lid margins (e.g. Chloramphenicol, Azithromycin, Bacitracin and Erythromycin)
Oral drugs of the tetracycline family or other systemic antibiotics (e.g. Oxytetracycline, Doxycycline, Minocycline, Lymecycline, and Azithromycin)

For Demodicosis treatments include

Ivermectin is an antiparasitic drug and can be used orally or topically
Metronidazole is an antibiotic and antiparasitic drug

DEWS III stresses the importance of education and adherence as core components of effective blepharitis management.

When patients understand the cause (bacteria vs oil vs mites), adherence improves.
Tailored plans reduce frustration and increase success with long‑term lid hygiene.

DEWS III guidance emphasises selecting interventions based on the specific pathological process, not one-size-fits-all care.

In Summary

Anterior blepharitis is a chronic inflammatory eyelid condition with multiple distinct causes: bacterial, seborrhoeic, or Demodex related.

TFOS DEWS III, encourages eyecare practitioners to identify the aetiological driver because:

Each subtype requires different, targeted treatments
Appropriate management improves symptom control, tear film stability, and dry eye outcomes
Tailored care enhances patient adherence and long‑term success

Misdiagnosis can lead to suboptimal treatment and ongoing disease progression

Supporting Materials

A number of resource materials are listed below that may support you in the management of patients with blepharitis. These may help provide information to your patient in a way that promotes compliance and understanding, whilst acknowledging that time is a common restriction for clinicians in most clinical settings.

This article serves as an overview of the condition and treatment options. It does not serve as a clinical guidance. Eyecare provider guidelines should be used when managing patients.